Provider Demographics
NPI:1275720856
Name:WATERMAN, JASON JOSEPH (MD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:JOSEPH
Last Name:WATERMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25821 VERMONT AVE
Mailing Address - Street 2:COASTLINE MEDICAL OFFICE - DEPARTMENT OF ORTHOPEDICS
Mailing Address - City:HARBOR CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90710-3518
Mailing Address - Country:US
Mailing Address - Phone:424-251-7371
Mailing Address - Fax:
Practice Address - Street 1:25821 VERMONT AVE
Practice Address - Street 2:COASTLINE MEDICAL OFFICE - DEPARTMENT OF ORTHOPEDICS
Practice Address - City:HARBOR CITY
Practice Address - State:CA
Practice Address - Zip Code:90710-3518
Practice Address - Country:US
Practice Address - Phone:424-251-7371
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-27
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA108207207RS0010X
PAMD440008207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Yes207RS0010XAllopathic & Osteopathic PhysiciansInternal MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA220442Medicare Oscar/Certification
PA2662448OtherHIGHMARK BLUE SHIELD
PA3845239000OtherKEYSTONE IBC
PA8634485OtherAETNA
PA220442YLJQMedicare PIN
PA1028227560001Medicaid