Provider Demographics
NPI:1154518918
Name:WATERS, GARY THOMAS (LMT)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:THOMAS
Last Name:WATERS
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9719 DEAN ACRE CT
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32825-6557
Mailing Address - Country:US
Mailing Address - Phone:407-497-9235
Mailing Address - Fax:407-249-2167
Practice Address - Street 1:9719 DEAN ACRE CT
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32825-6557
Practice Address - Country:US
Practice Address - Phone:407-497-9235
Practice Address - Fax:407-249-2167
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-26
Last Update Date:2007-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA24290171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor