Healthcare Provider Details

I. General information

NPI: 1417915547
Provider Name (Legal Business Name): MICHAEL G WATERS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2006
Last Update Date: 11/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4944 GREENSBORO RD
RIDGEWAY VA
24148-3390
US

IV. Provider business mailing address

142 S MAIN ST
DANVILLE VA
24541-2922
US

V. Phone/Fax

Practice location:
  • Phone: 276-956-2233
  • Fax: 276-956-1629
Mailing address:
  • Phone: 434-797-2828
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101045065
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: