Basic Information
| Provider Information | |||||||||
| NPI: | 1861439507 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WATERS | ||||||||
| FirstName: | EDWIN | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1515 N HARVARD AVE | ||||||||
| Address2: | SUITE E | ||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741154957 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9188326049 | ||||||||
| FaxNumber: | 9188326055 | ||||||||
| Practice Location | |||||||||
| Address1: | 12455 E 100TH ST N | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | OWASSO | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740554674 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9182745510 | ||||||||
| FaxNumber: | 9182745519 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2006 | ||||||||
| LastUpdateDate: | 02/09/2011 | ||||||||
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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 | 207Q00000X | 115331 | MO | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 25302 | OK | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 205336308 | 05 | MO | MEDICAID |