Provider Demographics
NPI:1619925211
Name:WATERMAN, DEBORAH (DPM)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:
Last Name:WATERMAN
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 S MAIN ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-3764
Mailing Address - Country:US
Mailing Address - Phone:860-638-4671
Mailing Address - Fax:860-638-4673
Practice Address - Street 1:210 S MAIN ST
Practice Address - Street 2:SUITE A
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457-3764
Practice Address - Country:US
Practice Address - Phone:860-638-4671
Practice Address - Fax:860-638-4673
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2012-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000735213E00000X, 213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC03117OtherMEDICARE ID
441574000Medicare PIN
CTU76049Medicare UPIN