Provider Demographics
NPI:1841272325
Name:WATERS, SUSAN (MD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:WATERS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:9750 NW 33RD ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33065-4042
Mailing Address - Country:US
Mailing Address - Phone:954-752-9220
Mailing Address - Fax:954-755-5025
Practice Address - Street 1:9750 NW 33RD ST
Practice Address - Street 2:SUITE 101
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33065-4042
Practice Address - Country:US
Practice Address - Phone:954-752-9220
Practice Address - Fax:954-755-5025
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2011-11-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME47691208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL048222600Medicaid
FL048222600Medicaid