Provider Demographics
NPI:1326007899
Name:WATERMAN, TIMOTHY ROY (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:ROY
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:PO BOX 1460
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:SD
Mailing Address - Zip Code:57402-1460
Mailing Address - Country:US
Mailing Address - Phone:605-622-5458
Mailing Address - Fax:605-622-5473
Practice Address - Street 1:815 1ST AVE SE
Practice Address - Street 2:SUITE 104
Practice Address - City:ABERDEEN
Practice Address - State:SD
Practice Address - Zip Code:57401-4602
Practice Address - Country:US
Practice Address - Phone:605-622-5458
Practice Address - Fax:605-622-5473
Is Sole Proprietor?:No
Enumeration Date:2006-03-22
Last Update Date:2015-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD3561207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6002550Medicaid
F27825Medicare UPIN
SD2154Medicare ID - Type Unspecified