Basic Information
| Provider Information | |||||||||
| NPI: | 1073539334 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | WATERS | ||||||||
| FirstName: | TUTASI | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 680 CENTRE ST | ||||||||
| Address2: | CREDENTIALING DEPARTMENT | ||||||||
| City: | BROCKTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023023308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5089417009 | ||||||||
| FaxNumber: | 5085832515 | ||||||||
| Practice Location | |||||||||
| Address1: | 2 WASHINGTON ST STE 210 | ||||||||
| Address2: | |||||||||
| City: | NORTH EASTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023561011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088948750 | ||||||||
| FaxNumber: | 5088948752 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2006 | ||||||||
| LastUpdateDate: | 05/22/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 205083 | MA | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 0110540 | 05 | MA | MEDICAID |