Basic Information
| Provider Information | |||||||||
| NPI: | 1295778801 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WATERSON | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2900 HANNAH BLVD | ||||||||
| Address2: | SUITE 212 | ||||||||
| City: | EAST LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488235384 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173191831 | ||||||||
| FaxNumber: | 5176642930 | ||||||||
| Practice Location | |||||||||
| Address1: | 315 TURWILL LN | ||||||||
| Address2: | |||||||||
| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490064231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2693438170 | ||||||||
| FaxNumber: | 2693828490 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2006 | ||||||||
| LastUpdateDate: | 09/25/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 5101013019 | MI | N | Allopathic & Osteopathic Physicians | Family Medicine | 207QS0010X | 5101013019 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0M21440047 | 01 | MI | MEDICARE ADVANTAGE | OTHER | 1022112 | 01 | MI | MCLAREN HEALTH PLAN-COMMERCIAL | OTHER | 200000001163 | 01 | MI | PHP FAMILYCARE | OTHER | 0153311575 | 01 | MI | BLUE CARE NETWORK | OTHER | 0153311575 | 01 | MI | BLUE CROSS BLUE SHIELD | OTHER | P00357559 | 01 | MI | RAILROAD MEDICARE | OTHER | 1022112 | 01 | MI | MCLAREN HEALTH PLAN-MEDICAID | OTHER | 1022112 | 01 | MI | MCLAREN HEALTH ADVANTAGE | OTHER | 200000001163 | 01 | MI | PHP | OTHER | 7778363 | 01 | MI | AETNA | OTHER | 4844348 | 05 | MI | MEDICAID |