Provider Demographics
NPI:1730186768
Name:WATERMAN, MICHAEL R (OD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:R
Last Name:WATERMAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 PARIS RD
Mailing Address - Street 2:
Mailing Address - City:NEW HARTFORD
Mailing Address - State:NY
Mailing Address - Zip Code:13413-2350
Mailing Address - Country:US
Mailing Address - Phone:315-797-9091
Mailing Address - Fax:315-797-9124
Practice Address - Street 1:1 PARIS RD
Practice Address - Street 2:
Practice Address - City:NEW HARTFORD
Practice Address - State:NY
Practice Address - Zip Code:13413-2350
Practice Address - Country:US
Practice Address - Phone:315-797-9091
Practice Address - Fax:315-797-9124
Is Sole Proprietor?:No
Enumeration Date:2005-07-06
Last Update Date:2009-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYVUT0005040152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02601898Medicaid
NYU10220Medicare UPIN
NYBB4873Medicare ID - Type Unspecified