Provider Demographics
NPI:1174606651
Name:WATERBURY, PAULA RUTH (DC)
Entity type:Individual
Prefix:DR
First Name:PAULA
Middle Name:RUTH
Last Name:WATERBURY
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:TAMARAC PLAZA
Mailing Address - Street 2:3991 ROUTE 2
Mailing Address - City:CROPSEYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12052
Mailing Address - Country:US
Mailing Address - Phone:518-279-0183
Mailing Address - Fax:518-279-0701
Practice Address - Street 1:TAMARAC PLAZA
Practice Address - Street 2:3991 ROUTE 2
Practice Address - City:CROPSEYVILLE
Practice Address - State:NY
Practice Address - Zip Code:12052
Practice Address - Country:US
Practice Address - Phone:518-279-0183
Practice Address - Fax:518-279-0701
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX009923-1111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYCO9923-6BOtherWORKERS COMPENSATION
NYX31301141830952OtherBC/BS
NY10058438OtherCDPHP
NYX31301141830952OtherBC/BS
NYCO9923-6BOtherWORKERS COMPENSATION