Provider Demographics
NPI:1386932564
Name:WATERS, DAVID EUGENE (DPM)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:EUGENE
Last Name:WATERS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2799 W GRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-2608
Mailing Address - Country:US
Mailing Address - Phone:313-433-2089
Mailing Address - Fax:
Practice Address - Street 1:620 N DENVER AVE
Practice Address - Street 2:
Practice Address - City:HASTINGS
Practice Address - State:NE
Practice Address - Zip Code:68901-5122
Practice Address - Country:US
Practice Address - Phone:402-463-1355
Practice Address - Fax:402-463-6947
Is Sole Proprietor?:No
Enumeration Date:2011-07-21
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5315089804213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5901002399Medicaid