Provider Demographics
NPI:1730384132
Name:WATERS, ROGER (MD)
Entity type:Individual
Prefix:DR
First Name:ROGER
Middle Name:
Last Name:WATERS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3388 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSON
Mailing Address - State:NY
Mailing Address - Zip Code:14589-9352
Mailing Address - Country:US
Mailing Address - Phone:315-589-9657
Mailing Address - Fax:315-589-9406
Practice Address - Street 1:7571 STATE ROUTE 54
Practice Address - Street 2:
Practice Address - City:BATH
Practice Address - State:NY
Practice Address - Zip Code:14810-9504
Practice Address - Country:US
Practice Address - Phone:585-247-6810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY099035-1207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYC88900Medicare UPIN