Provider Demographics
NPI:1053346908
Name:WATERS, WILLIAM FREDERICK (PHD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:FREDERICK
Last Name:WATERS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10310 THE GROVE BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70836-6455
Mailing Address - Country:US
Mailing Address - Phone:225-761-5200
Mailing Address - Fax:
Practice Address - Street 1:9001 SUMMA AVE
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809-3726
Practice Address - Country:US
Practice Address - Phone:225-761-5200
Practice Address - Fax:225-761-5512
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2019-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA347207RP1001X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1530760Medicaid
LA5X2996629Medicare PIN
LA5X299Medicare PIN
S41219Medicare UPIN