Provider Demographics
NPI:1710006432
Name:WATERMAN, E. MARK (AH, DC, IDE)
Entity Type:Individual
Prefix:DR
First Name:E.
Middle Name:MARK
Last Name:WATERMAN
Suffix:
Gender:M
Credentials:AH, DC, IDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2440 W. ARROW ROUTE
Mailing Address - Street 2:SUITE 5A
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-9450
Mailing Address - Country:US
Mailing Address - Phone:909-670-2225
Mailing Address - Fax:909-670-2227
Practice Address - Street 1:2440 W. ARROW ROUTE
Practice Address - Street 2:SUITE 5A
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-9450
Practice Address - Country:US
Practice Address - Phone:909-670-2225
Practice Address - Fax:909-670-2227
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2015-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODC19321111N00000X
CADC19321111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor