Provider Demographics
NPI:1154543684
Name:WATERS, BRIAN MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:MICHAEL
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 1:8722 MELROSE
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78250
Mailing Address - Country:US
Mailing Address - Phone:210-410-9757
Mailing Address - Fax:
Practice Address - Street 1:2200 BERGQUIST DRIVE
Practice Address - Street 2:WILFORD HALL MEDICAL CENTER
Practice Address - City:LACKLAND AFB
Practice Address - State:TX
Practice Address - Zip Code:78236-5300
Practice Address - Country:US
Practice Address - Phone:210-292-7361
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI491122084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry