Provider Demographics
NPI:1144682154
Name:WATERS, DAVID MICHAEL (MD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:MICHAEL
Last Name:WATERS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:710 N FAIRBANKS CT STE 2-458
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-3013
Mailing Address - Country:US
Mailing Address - Phone:312-926-3211
Mailing Address - Fax:312-503-8259
Practice Address - Street 1:710 N FAIRBANKS CT STE 2-458
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-3013
Practice Address - Country:US
Practice Address - Phone:312-926-3211
Practice Address - Fax:312-503-8259
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-28
Last Update Date:2022-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036148254207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology