Provider Demographics
NPI:1841699790
Name:WATERS, EDWARD WILLIAM
Entity type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:WILLIAM
Last Name:WATERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6938 DAYTON RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32210-2763
Mailing Address - Country:US
Mailing Address - Phone:904-210-0085
Mailing Address - Fax:904-693-0360
Practice Address - Street 1:6938 DAYTON RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32210-2763
Practice Address - Country:US
Practice Address - Phone:904-210-0085
Practice Address - Fax:904-693-0360
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-16
Last Update Date:2014-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL242841172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver