Provider Demographics
NPI:1144299918
Name:WATERS, RENEE LATRESE (MD)
Entity type:Individual
Prefix:
First Name:RENEE
Middle Name:LATRESE
Last Name:WATERS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3651 DAWSON FOREST RD E
Mailing Address - Street 2:SUITE 100
Mailing Address - City:DAWSONVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30534-0404
Mailing Address - Country:US
Mailing Address - Phone:706-216-7337
Mailing Address - Fax:770-783-8899
Practice Address - Street 1:3651 DAWSON FOREST RD E
Practice Address - Street 2:SUITE 100
Practice Address - City:DAWSONVILLE
Practice Address - State:GA
Practice Address - Zip Code:30534-0404
Practice Address - Country:US
Practice Address - Phone:706-216-7337
Practice Address - Fax:770-783-8899
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2011-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA035782208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000650339DMedicaid