Basic Information
| Provider Information | |||||||||
| NPI: | 1881662625 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WATERLOO FAMILY PRACTICE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 361 E WATERLOO RD | ||||||||
| Address2: | |||||||||
| City: | AKRON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3307737866 | ||||||||
| FaxNumber: | 3307735090 | ||||||||
| Practice Location | |||||||||
| Address1: | 361 E WATERLOO RD | ||||||||
| Address2: | |||||||||
| City: | AKRON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3307737866 | ||||||||
| FaxNumber: | 3307735090 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2006 | ||||||||
| LastUpdateDate: | 12/11/2007 | ||||||||
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| AuthorizedOfficialLastName: | OSOTEO | ||||||||
| AuthorizedOfficialFirstName: | RAFAEL | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3307737866 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.