Basic Information
| Provider Information | |||||||||
| NPI: | 1982773685 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WATERS | ||||||||
| FirstName: | SALLIE | ||||||||
| MiddleName: | JANE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | STURDEVANT | ||||||||
| OtherFirstName: | SALLIE | ||||||||
| OtherMiddleName: | JANE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1313 JACKIE RD. | ||||||||
| Address2: | WATERS FAMILY MEDICINE | ||||||||
| City: | DUNCAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 73533 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5802518212 | ||||||||
| FaxNumber: | 5802521020 | ||||||||
| Practice Location | |||||||||
| Address1: | 1313 JACKIE RD. | ||||||||
| Address2: | |||||||||
| City: | DUNCAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 73533 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5802518212 | ||||||||
| FaxNumber: | 5802521020 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2006 | ||||||||
| LastUpdateDate: | 12/16/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 23254 | OK | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200014900A | 05 | OK | MEDICAID |