Healthcare Provider Details

I. General information

NPI: 1043281579
Provider Name (Legal Business Name): KATHERINE MARIE WATERS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 HIGH SERVICE AVE
NORTH PROVIDENCE RI
02904-5113
US

IV. Provider business mailing address

87 ANNETTE DR
PORTSMOUTH RI
02871-3703
US

V. Phone/Fax

Practice location:
  • Phone: 401-456-3155
  • Fax: 401-456-3156
Mailing address:
  • Phone: 401-682-2248
  • Fax: 401-456-3156

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number7169
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number80241
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: