Provider Demographics
NPI:1912102229
Name:WATERS, THADDEUS PATRICK (MD)
Entity Type:Individual
Prefix:
First Name:THADDEUS
Middle Name:PATRICK
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 1:8869 LAKE GLEN CT
Mailing Address - Street 2:
Mailing Address - City:CLARENCE CENTER
Mailing Address - State:NY
Mailing Address - Zip Code:14032-9406
Mailing Address - Country:US
Mailing Address - Phone:216-258-4294
Mailing Address - Fax:
Practice Address - Street 1:1001 MAIN ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14203-1009
Practice Address - Country:US
Practice Address - Phone:716-323-0615
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-18
Last Update Date:2022-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35089915207V00000X
IL036131903207VM0101X
NY314132207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3068782Medicaid