Provider Demographics
NPI:1114400918
Name:WATTERS, NICHOLAS GREGORY (SUB IDC)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:GREGORY
Last Name:WATTERS
Suffix:
Gender:
Credentials:SUB IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 BRUNNERS LN
Mailing Address - Street 2:
Mailing Address - City:MONCKS CORNER
Mailing Address - State:SC
Mailing Address - Zip Code:29461-8896
Mailing Address - Country:US
Mailing Address - Phone:808-979-5637
Mailing Address - Fax:
Practice Address - Street 1:1 WAHOO AVE
Practice Address - Street 2:
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06349-2324
Practice Address - Country:US
Practice Address - Phone:904-680-8007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-08
Last Update Date:2025-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman