Provider Demographics
NPI:1144272543
Name:WATERMAN, JANE LYNN (MD)
Entity type:Individual
Prefix:
First Name:JANE
Middle Name:LYNN
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 1:6235 GARFIELD RD
Mailing Address - Street 2:
Mailing Address - City:WOLCOTT
Mailing Address - State:VT
Mailing Address - Zip Code:05680-4311
Mailing Address - Country:US
Mailing Address - Phone:802-888-9280
Mailing Address - Fax:
Practice Address - Street 1:6235 GARFIELD RD
Practice Address - Street 2:
Practice Address - City:WOLCOTT
Practice Address - State:VT
Practice Address - Zip Code:05680-4311
Practice Address - Country:US
Practice Address - Phone:802-888-9280
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC51611207P00000X, 207Q00000X
VT042-0010248207P00000X
AZ21800207P00000X, 207Q00000X
ME013878207P00000X, 207Q00000X
VT207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C516110Medicaid
CAF72769Medicare UPIN