Provider Demographics
NPI:1649351362
Name:WATERS, MICHAEL K (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:K
Last Name:WATERS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 SHARMAN DR
Mailing Address - Street 2:
Mailing Address - City:NORWICH
Mailing Address - State:NY
Mailing Address - Zip Code:13815-3183
Mailing Address - Country:US
Mailing Address - Phone:607-334-7149
Mailing Address - Fax:
Practice Address - Street 1:179 N BROAD ST
Practice Address - Street 2:
Practice Address - City:NORWICH
Practice Address - State:NY
Practice Address - Zip Code:13815-1019
Practice Address - Country:US
Practice Address - Phone:607-337-7045
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY190029207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01349499Medicaid
NYE10672Medicare UPIN
NY01349499Medicaid