Basic Information
Provider Information | |||||||||
NPI: | 1306045877 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WATERS | ||||||||
FirstName: | JUSTIN | ||||||||
MiddleName: | ROBERT | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1535 | ||||||||
Address2: |   | ||||||||
City: | TACOMA | ||||||||
State: | WA | ||||||||
PostalCode: | 984011535 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2537614200 | ||||||||
FaxNumber: | 2533833553 | ||||||||
Practice Location | |||||||||
Address1: | 1304 FAWCETT AVE STE 100 | ||||||||
Address2: |   | ||||||||
City: | TACOMA | ||||||||
State: | WA | ||||||||
PostalCode: | 984021900 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2537614200 | ||||||||
FaxNumber: | 2537614201 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/16/2007 | ||||||||
LastUpdateDate: | 01/10/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | MD165195 | OR | N |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085N0700X | MD60344894 | WA | Y |   | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085N0700X | MD165195 | OR | N |   | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085R0202X | MD60344894 | WA | N |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
ID | Type | State | Issuer | Description | 500671344 | 05 | OR |   | MEDICAID | 2028591 | 05 | WA |   | MEDICAID |