Provider Demographics
NPI:1003447400
Name:WATERMAN, FORREST MARK (OD)
Entity Type:Individual
Prefix:DR
First Name:FORREST
Middle Name:MARK
Last Name:WATERMAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4350 TANNER RD
Mailing Address - Street 2:
Mailing Address - City:NEDROW
Mailing Address - State:NY
Mailing Address - Zip Code:13120-9719
Mailing Address - Country:US
Mailing Address - Phone:315-481-3279
Mailing Address - Fax:
Practice Address - Street 1:928 NJ-73
Practice Address - Street 2:
Practice Address - City:EVESHAM TOWNSHIP
Practice Address - State:NJ
Practice Address - Zip Code:08053
Practice Address - Country:US
Practice Address - Phone:856-596-8883
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-04
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NJ27OA00695100152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program