Provider Demographics
NPI:1588623128
Name:WATERMAN, JACK (DO)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:WATERMAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:900 VILLAGE SQUARE CROSSING
Mailing Address - Street 2:SUITE 250
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33410-4551
Mailing Address - Country:US
Mailing Address - Phone:561-962-0101
Mailing Address - Fax:561-425-5188
Practice Address - Street 1:900 VILLAGE SQUARE CROSSING
Practice Address - Street 2:SUITE 250
Practice Address - City:PALM BEACH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33410-4551
Practice Address - Country:US
Practice Address - Phone:561-962-0101
Practice Address - Fax:561-425-5188
Is Sole Proprietor?:No
Enumeration Date:2006-03-22
Last Update Date:2018-12-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLOS0005237207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL045840600Medicaid
FLD60776Medicare UPIN
FL045840600Medicaid