Provider Demographics
NPI:1528075454
Name:WATERS, JERRY DEE (MD)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:DEE
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 1:236 W EAST AVE
Mailing Address - Street 2:PMB 323
Mailing Address - City:CHICO
Mailing Address - State:CA
Mailing Address - Zip Code:95926-7235
Mailing Address - Country:US
Mailing Address - Phone:530-538-3020
Mailing Address - Fax:530-533-4243
Practice Address - Street 1:2721 OLIVE HWY
Practice Address - Street 2:STE 9
Practice Address - City:OROVILLE
Practice Address - State:CA
Practice Address - Zip Code:95966-6115
Practice Address - Country:US
Practice Address - Phone:530-538-3020
Practice Address - Fax:530-533-4243
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-02
Last Update Date:2012-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG44051208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00276055OtherMEDICARE RAILROAD #
CA00G440510Medicaid
P00084218OtherRAILROAD MEDICARE RRM
CA00G440512Medicare PIN
CA00G440510Medicaid
A49533Medicare UPIN