Healthcare Provider Details

I. General information

NPI: 1619924727
Provider Name (Legal Business Name): THOMAS ANDREW WATERS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9500 EUCLID AVE # E-19
CLEVELAND OH
44195-0001
US

IV. Provider business mailing address

39063 CAMELOT WAY
AVON OH
44011-3627
US

V. Phone/Fax

Practice location:
  • Phone: 216-445-4590
  • Fax: 216-444-1703
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number35069514W
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: