Healthcare Provider Details

I. General information

NPI: 1730477621
Provider Name (Legal Business Name): ELIZABETH J. WATERS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2011
Last Update Date: 01/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

292 EUCLID AVE SUITE 220
SAN DIEGO CA
92114-3629
US

IV. Provider business mailing address

292 EUCLID AVE SUITE 220
SAN DIEGO CA
92114-3629
US

V. Phone/Fax

Practice location:
  • Phone: 619-262-8624
  • Fax: 619-262-6639
Mailing address:
  • Phone: 619-262-8624
  • Fax: 619-262-6639

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA113933
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: