Provider Demographics
NPI:1194922245
Name:WATERFORD MEDICAL LTD
Entity type:Organization
Organization Name:WATERFORD MEDICAL LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SANJOY
Authorized Official - Middle Name:
Authorized Official - Last Name:MAJUMDAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:630-820-6730
Mailing Address - Street 1:5958 W LAWRENCE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60630-3130
Mailing Address - Country:US
Mailing Address - Phone:773-282-4572
Mailing Address - Fax:630-820-6730
Practice Address - Street 1:5958 W LAWRENCE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60630-3130
Practice Address - Country:US
Practice Address - Phone:773-282-4572
Practice Address - Fax:630-820-6730
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-02
Last Update Date:2010-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036056086207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILC44103Medicare UPIN
IL778390Medicare ID - Type Unspecified