Basic Information
| Provider Information | |||||||||
| NPI: | 1629140561 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WATERS | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | FARRIS | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2910 N 3RD AVE # 470 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850134434 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6024066262 | ||||||||
| FaxNumber: | 6024066261 | ||||||||
| Practice Location | |||||||||
| Address1: | 2910 N 3RD AVE # 470 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850134434 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6024066262 | ||||||||
| FaxNumber: | 6024066261 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2006 | ||||||||
| LastUpdateDate: | 05/27/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | A78335 | CA | N | Other Service Providers | Specialist | 2084N0400X | ME86883 | FL | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | 52108 | AZ | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084V0102X | 52108 | AZ | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Vascular Neurology |
ID Information
| ID | Type | State | Issuer | Description | 279658900 | 05 | FL | MEDICAID |