Healthcare Provider Details

I. General information

NPI: 1568440717
Provider Name (Legal Business Name): KURTIS ALLEN WATERS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/06/2006
Last Update Date: 08/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13359 ISLE DR SUITE 1
BAXTER MN
56425-2221
US

IV. Provider business mailing address

13359 ISLE DR SUITE 1
BAXTER MN
56425-2221
US

V. Phone/Fax

Practice location:
  • Phone: 218-454-8888
  • Fax:
Mailing address:
  • Phone: 218-454-8888
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number37843
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: