Healthcare Provider Details

I. General information

NPI: 1316147457
Provider Name (Legal Business Name): MICHAEL WATERS IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2007
Last Update Date: 07/18/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14900 PARK CENTRAL ROAD NAVAL SUPPORT FACILITY
THURMONT MD
21788
US

IV. Provider business mailing address

10384 CHAMBERLIN COURT EAST
WALDORF MD
20601
US

V. Phone/Fax

Practice location:
  • Phone: 301-271-1460
  • Fax:
Mailing address:
  • Phone: 301-535-7900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: