Basic Information
| Provider Information | |||||||||
| NPI: | 1326064601 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WATERER | ||||||||
| FirstName: | HENRY | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | III | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 501 MARSHALL ST | ||||||||
| Address2: | STE 104 | ||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392021651 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019696404 | ||||||||
| FaxNumber: | 6019734541 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 MARSHALL ST | ||||||||
| Address2: | STE 104 | ||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392021651 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019696404 | ||||||||
| FaxNumber: | 6019734541 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2006 | ||||||||
| LastUpdateDate: | 10/23/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 11093 | MS | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 00117115 | 05 | MS | MEDICAID |