1700197977 NPI number — HEATHER ELIZABETH WATERS DO

Table of content: HEATHER ELIZABETH WATERS DO (NPI 1700197977)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700197977 NPI number — HEATHER ELIZABETH WATERS DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WATERS
Provider First Name:
HEATHER
Provider Middle Name:
ELIZABETH
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
AULTMAN
Provider Other First Name:
HEATHER
Provider Other Middle Name:
ELIZABETH WHITE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1700197977
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/15/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1729
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HATTIESBURG
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39403-1729
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-545-8700
Provider Business Mailing Address Fax Number:
601-255-2645

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
596 W 11TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LUMBERTON
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39455-2350
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-596-4215
Provider Business Practice Location Address Fax Number:
601-796-9437
Provider Enumeration Date:
06/23/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  21796 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 21796 . This is a "MS MEDICAL LICENSE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 008504826 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com