Individual
DR. THERESA A WATERS
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
D. O.
Contact information
Practice address
510 TOWNE DR, FAYETTEVILLE, NY 13066-1331
(315) 663-0500
(315) 663-0514
Mailing address
510 TOWNE DR, FAYETTEVILLE, NY 13066-1331
(315) 663-0500
(315) 663-0514
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
285798
NY
207RC0000X
Cardiovascular Disease Physician
Primary
285798
NY
390200000X
Student in an Organized Health Care Education/Training Program
61027
NY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
04561226
—
NY
Enumeration date
04/07/2010
Last updated
09/27/2019
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