Provider Demographics
NPI:1568440717
Name:WATERS, KURTIS ALLEN (MD)
Entity type:Individual
Prefix:DR
First Name:KURTIS
Middle Name:ALLEN
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 1:13359 ISLE DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:BAXTER
Mailing Address - State:MN
Mailing Address - Zip Code:56425-2221
Mailing Address - Country:US
Mailing Address - Phone:218-454-8888
Mailing Address - Fax:
Practice Address - Street 1:13359 ISLE DR
Practice Address - Street 2:SUITE 1
Practice Address - City:BAXTER
Practice Address - State:MN
Practice Address - Zip Code:56425-2221
Practice Address - Country:US
Practice Address - Phone:218-454-8888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-06
Last Update Date:2011-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN37843207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNP00409713OtherPALMETTO - RAILROAD MEDICARE
MN422K8WAOtherBLUE CROSS BLUE SHIELD MN
MN930218200Medicaid
MN040000502Medicare ID - Type Unspecified
MN930218200Medicaid