Provider Demographics
NPI:1982773685
Name:WATERS, SALLIE JANE (MD)
Entity Type:Individual
Prefix:
First Name:SALLIE
Middle Name:JANE
Last Name:WATERS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SALLIE
Other - Middle Name:JANE
Other - Last Name:STURDEVANT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1313 JACKIE RD.
Mailing Address - Street 2:WATERS FAMILY MEDICINE
Mailing Address - City:DUNCAN
Mailing Address - State:OK
Mailing Address - Zip Code:73533
Mailing Address - Country:US
Mailing Address - Phone:580-251-8212
Mailing Address - Fax:580-252-1020
Practice Address - Street 1:1313 JACKIE RD.
Practice Address - Street 2:
Practice Address - City:DUNCAN
Practice Address - State:OK
Practice Address - Zip Code:73533
Practice Address - Country:US
Practice Address - Phone:580-251-8212
Practice Address - Fax:580-252-1020
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2008-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK23254207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200014900AMedicaid
OK200014900AMedicaid