Healthcare Provider Details

I. General information

NPI: 1124015896
Provider Name (Legal Business Name): HARRIS JOHN WATERS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2005
Last Update Date: 05/26/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 WELCH ST
SILVERTON OR
97381-1934
US

IV. Provider business mailing address

450 WELCH ST
SILVERTON OR
97381-1934
US

V. Phone/Fax

Practice location:
  • Phone: 503-873-5310
  • Fax: 503-873-5315
Mailing address:
  • Phone: 503-873-5310
  • Fax: 503-873-5315

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMD15831
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: