Provider Demographics
NPI:1982632527
Name:WATERMAN, GARY LEE (DO)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:LEE
Last Name:WATERMAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:RI
Mailing Address - Zip Code:02842-5237
Mailing Address - Country:US
Mailing Address - Phone:401-239-1800
Mailing Address - Fax:401-239-1793
Practice Address - Street 1:102 VALLEY RD
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:RI
Practice Address - Zip Code:02842-5237
Practice Address - Country:US
Practice Address - Phone:401-239-1800
Practice Address - Fax:401-239-1793
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS 4781207NS0135X
PAOS005797L207N00000X
RIDO01051207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
INE67481Medicare UPIN
INM400015725Medicare PIN