Basic Information
| Provider Information | |||||||||
| NPI: | 1649381658 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WATERMAN | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | ROGER | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 BRIGHTON LN | ||||||||
| Address2: | |||||||||
| City: | SIMSBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060701543 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606589309 | ||||||||
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| Practice Location | |||||||||
| Address1: | 555 WILLARD AVE | ||||||||
| Address2: | |||||||||
| City: | NEWINGTON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061112631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606676882 | ||||||||
| FaxNumber: | 8606676875 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 207RR0500X | 032961 | CT | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology |
No ID Information.