Provider Demographics
NPI:1902877293
Name:WATERS, STEPHEN MICHAEL (DC)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:MICHAEL
Last Name:WATERS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:974 ISABEL DR
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:PA
Mailing Address - Zip Code:17042-7482
Mailing Address - Country:US
Mailing Address - Phone:717-277-0612
Mailing Address - Fax:717-277-0613
Practice Address - Street 1:974 ISABEL DR
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:PA
Practice Address - Zip Code:17042-7482
Practice Address - Country:US
Practice Address - Phone:717-277-0612
Practice Address - Fax:717-277-0613
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-27
Last Update Date:2016-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC-007292-L111N00000X
PAAJ-007292-L111NX0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No111NX0100XChiropractic ProvidersChiropractorOccupational Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0763651000OtherINDEPENDENCE BLUE CROSS
PA1033499OtherASHN
PA50013490OtherCAPITAL BLUE CROSS
PA1696780OtherHIGHMARK BLUE SHIELD
PA022829Medicare ID - Type Unspecified
PA0763651000OtherINDEPENDENCE BLUE CROSS