Provider Demographics
NPI:1477997146
Name:WATERMAN, MEGAN R (MD)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:R
Last Name:WATERMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-2957
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:180 PARK AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-2957
Practice Address - Country:US
Practice Address - Phone:207-874-2141
Practice Address - Fax:207-874-2164
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-24
Last Update Date:2017-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125063557207Q00000X
MEMD21755207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine