Provider Demographics
NPI:1316147457
Name:WATERS, MICHAEL (IDC)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:WATERS
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10384 CHAMBERLIN COURT EAST
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20601
Mailing Address - Country:US
Mailing Address - Phone:301-535-7900
Mailing Address - Fax:
Practice Address - Street 1:14900 PARK CENTRAL ROAD
Practice Address - Street 2:NAVAL SUPPORT FACILITY
Practice Address - City:THURMONT
Practice Address - State:MD
Practice Address - Zip Code:21788
Practice Address - Country:US
Practice Address - Phone:301-271-1460
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-18
Last Update Date:2007-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman