1710006432 NPI number — DR. E. MARK WATERMAN AH, DC, IDE

Table of content: DR. E. MARK WATERMAN AH, DC, IDE (NPI 1710006432)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710006432 NPI number — DR. E. MARK WATERMAN AH, DC, IDE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WATERMAN
Provider First Name:
E.
Provider Middle Name:
MARK
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
AH, DC, IDE
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1710006432
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/30/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2440 W. ARROW ROUTE
Provider Second Line Business Mailing Address:
SUITE 5A
Provider Business Mailing Address City Name:
UPLAND
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91786-9450
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-670-2225
Provider Business Mailing Address Fax Number:
909-670-2227

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2440 W. ARROW ROUTE
Provider Second Line Business Practice Location Address:
SUITE 5A
Provider Business Practice Location Address City Name:
UPLAND
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91786-9450
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-670-2225
Provider Business Practice Location Address Fax Number:
909-670-2227
Provider Enumeration Date:
03/28/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  DC19321 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 111N00000X , with the licence number: DC19321 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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