Healthcare Provider Details

I. General information

NPI: 1811065584
Provider Name (Legal Business Name): KENNETH W WATERS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/01/2006
Last Update Date: 07/23/2021
Certification Date: 06/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

KAISER PERMANENTE TYSONS CORNER MEDICAL CENTER 8008 WESTPARK DRIVE
MCLEAN VA
22102
US

IV. Provider business mailing address

8008 WESTPARK DRIVE MAPMG DEPT OF ANESTHESIA
MCLEAN VA
22102
US

V. Phone/Fax

Practice location:
  • Phone: 703-489-1405
  • Fax:
Mailing address:
  • Phone: 703-489-1405
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberD0068100
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberMD044841
License Number StateDC
# 3
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberMD17452
License Number StateME
# 4
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberEC-05-170
License Number StateME
# 5
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number0101252186
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: