Provider Demographics
NPI:1295778801
Name:WATERSON, DAVID C (DO)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:C
Last Name:WATERSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 JOHN STREET
Mailing Address - Street 2:BOX 42
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:315 TURWILL LN
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49006-4231
Practice Address - Country:US
Practice Address - Phone:269-343-8170
Practice Address - Fax:269-382-8490
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101013019207QS0010X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4844348Medicaid
MI7778363OtherAETNA
MIP00357559OtherRAILROAD MEDICARE
MI0M21440047OtherMEDICARE ADVANTAGE
MI1022112OtherMCLAREN HEALTH PLAN-MEDICAID
MI0153311575OtherBLUE CROSS BLUE SHIELD
MI200000001163OtherPHP
MI200000001163OtherPHP FAMILYCARE
MI0153311575OtherBLUE CARE NETWORK
MI1022112OtherMCLAREN HEALTH ADVANTAGE
MI1022112OtherMCLAREN HEALTH PLAN-COMMERCIAL
MI1022112OtherMCLAREN HEALTH PLAN-MEDICAID
MIP00357559OtherRAILROAD MEDICARE