Healthcare Provider Details

I. General information

NPI: 1972535615
Provider Name (Legal Business Name): DONALD B. WATERS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 10/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 E CARTER AVE
BLACKSHEAR GA
31516-1561
US

IV. Provider business mailing address

120 E CARTER AVE
BLACKSHEAR GA
31516-1561
US

V. Phone/Fax

Practice location:
  • Phone: 912-449-4426
  • Fax: 912-449-1517
Mailing address:
  • Phone: 912-449-4426
  • Fax: 912-449-1517

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number13804
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: