Provider Demographics
NPI:1215972278
Name:WATERS, WILLIAM C IV (MD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:C
Last Name:WATERS
Suffix:IV
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:PO BOX 1845
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30112-0035
Mailing Address - Country:US
Mailing Address - Phone:770-832-1488
Mailing Address - Fax:
Practice Address - Street 1:705 DIXIE ST
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-3818
Practice Address - Country:US
Practice Address - Phone:770-832-1488
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA029969207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA306327OtherWELLCARE
GA10049622OtherAMERIGROUP
GAO76971Medicare UPIN
GA10049622OtherAMERIGROUP