Healthcare Provider Details

I. General information

NPI: 1457612319
Provider Name (Legal Business Name): J ALAN WATERS JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2012
Last Update Date: 06/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

747 BROADWAY, SUITE 739 WEST SWEDISH MEDICAL CENTER, GENERAL SURGERY PROGRAM
SEATTLE TX
98101-4307
US

IV. Provider business mailing address

1330 BOREN AVE APT 305
SEATTLE WA
98101-2717
US

V. Phone/Fax

Practice location:
  • Phone: 206-386-2123
  • Fax:
Mailing address:
  • Phone: 210-310-8185
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: