Healthcare Provider Details

I. General information

NPI: 1841699790
Provider Name (Legal Business Name): MR. EDWARD WILLIAM WATERS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2014
Last Update Date: 08/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6938 DAYTON RD
JACKSONVILLE FL
32210-2763
US

IV. Provider business mailing address

6938 DAYTON RD
JACKSONVILLE FL
32210-2763
US

V. Phone/Fax

Practice location:
  • Phone: 904-210-0085
  • Fax: 904-693-0360
Mailing address:
  • Phone: 904-210-0085
  • Fax: 904-693-0360

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number242841
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: