MEDICARE: JUDITH KUCZEK WATERS MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	35-06-7582-W	OH

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	080163899	OTHER	OH	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	86542	OTHER	OH	QUAL CHOICE
4	0007634033	OTHER	OH	AETNA
5	341652755011	OTHER	OH	TRICARE
6	000000077081	OTHER	OH	ANTHEM PIN
7	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
8	0843940002	OTHER	OH	DMERC
9	3416527556P00	OTHER	OH	ANTHEM GROUP

General Provider Information

NPI Number	:	1134106974
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JUDITH KUCZEK WATERS MD

Provider Business Mailing Address
First Line	:	PO BOX 30610
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44130-0610
Country	:	US
Telephone Number	:	440-816-6429
Fax Number	:	440-816-6438

Provider Business Practice Location Address
First Line	:	18181 PEARL RD
Second Line	:	B202
City	:	STRONGSVILLE
State	:	OH
Zip	:	44136-6949
Country	:	US
Telephone Number	:	440-816-4960
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/22/2005
Last Update Date	:	12/28/2020

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