Basic Information
| Provider Information | |||||||||
| NPI: | 1720084718 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WATERS | ||||||||
| FirstName: | PATRICK | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2800 HAYES AVE | ||||||||
| Address2: | BLDG D | ||||||||
| City: | SANDUSKY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 448707252 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4196278771 | ||||||||
| FaxNumber: | 4196270363 | ||||||||
| Practice Location | |||||||||
| Address1: | 2800 HAYES AVE | ||||||||
| Address2: | BLDG D | ||||||||
| City: | SANDUSKY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 448707252 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4196278771 | ||||||||
| FaxNumber: | 4196270363 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2005 | ||||||||
| LastUpdateDate: | 10/17/2007 | ||||||||
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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 | 208800000X | 35071687 | OH | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 000000204296 | 01 | OH | ANTHEM | OTHER | 2592762 | 01 | OH | AETNA | OTHER | 04073 | 01 | OH | PARAMOUNT | OTHER | 2046119 | 05 | OH | MEDICAID |