Provider Demographics
NPI:1811965908
Name:WATERS, MICHAEL L (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:L
Last Name:WATERS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 45443
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84145-0443
Mailing Address - Country:US
Mailing Address - Phone:904-202-1032
Mailing Address - Fax:904-376-4107
Practice Address - Street 1:13001 ATLANTIC BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32225-3123
Practice Address - Country:US
Practice Address - Phone:904-221-0264
Practice Address - Fax:904-221-5141
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2018-12-31
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLME66649207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL080162830OtherRAILROAD MEDICARE
FL3796639-00Medicaid
FL080162830OtherRAILROAD MEDICARE
F29131Medicare UPIN