MEDICARE: ZACHRY LANE WATERSON DO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	0200245A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	000000222712	OTHER	BLUE CROSS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	000000015336	OTHER	MPLAN

General Provider Information

NPI Number	:	1902842677
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ZACHRY LANE WATERSON DO

Provider Business Mailing Address
First Line	:	750 BROADWAY
Second Line	:	SUITE 150
City	:	FORT WAYNE
State	:	IN
Zip	:	46802-1411
Country	:	US
Telephone Number	:	260-423-2682
Fax Number	:	260-422-4326

Provider Business Practice Location Address
First Line	:	750 BROADWAY
Second Line	:	SUITE 350
City	:	FORT WAYNE
State	:	IN
Zip	:	46802-1411
Country	:	US
Telephone Number	:	260-423-2682
Fax Number	:	260-422-4326

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/21/2006
Last Update Date	:	06/03/2011

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Directions to “ ZACHRY LANE WATERSON DO” Practice Location

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