Provider Demographics
NPI:1174543904
Name:WATERSIDE WOMENS MEDICAL CARE PC
Entity type:Organization
Organization Name:WATERSIDE WOMENS MEDICAL CARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:DAMIAN
Authorized Official - Last Name:LOPES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:914-528-7664
Mailing Address - Street 1:205 WATERSIDE PROFESSIONAL PARK
Mailing Address - Street 2:SUITE 205
Mailing Address - City:PUTNAM VALLEY
Mailing Address - State:NY
Mailing Address - Zip Code:10579-3505
Mailing Address - Country:US
Mailing Address - Phone:914-528-7664
Mailing Address - Fax:914-526-2386
Practice Address - Street 1:205 WATERSIDE PROFESSIONAL PARK
Practice Address - Street 2:SUITE 205
Practice Address - City:PUTNAM VALLEY
Practice Address - State:NY
Practice Address - Zip Code:10579-3505
Practice Address - Country:US
Practice Address - Phone:914-528-7664
Practice Address - Fax:914-526-2386
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2008-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYWEK761Medicare PIN