Basic Information
Provider Information | |||||||||
NPI: | 1457333650 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WATERS-HWANG | ||||||||
FirstName: | DOROTHY | ||||||||
MiddleName: | SHANNON | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | WATERS | ||||||||
OtherFirstName: | DOROTHY | ||||||||
OtherMiddleName: | SHANNON | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 2350 SCHILLINGER ROAD S | ||||||||
Address2: |   | ||||||||
City: | MOBILE | ||||||||
State: | AL | ||||||||
PostalCode: | 36695 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2514457614 | ||||||||
FaxNumber: | 2514106127 | ||||||||
Practice Location | |||||||||
Address1: | 2350 SCHILLINGER ROAD S | ||||||||
Address2: |   | ||||||||
City: | MOBILE | ||||||||
State: | AL | ||||||||
PostalCode: | 36695 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2514457614 | ||||||||
FaxNumber: | 2514106127 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/15/2005 | ||||||||
LastUpdateDate: | 02/09/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/09/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 26064 | AL | N |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   | 207R00000X | M-13371 | ID | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207P00000X | 33210 | KY | Y |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 51523731 | 01 | AL | BLUE CROSS BLUE SHIELD | OTHER |