Provider Demographics
NPI:1457359226
Name:WATERMAN, WAYNE ROBERT (DO)
Entity type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:ROBERT
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 1:43 WHITING HILL RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:BREWER
Mailing Address - State:ME
Mailing Address - Zip Code:04412-1005
Mailing Address - Country:US
Mailing Address - Phone:207-973-5000
Mailing Address - Fax:207-973-5042
Practice Address - Street 1:417 STATE ST
Practice Address - Street 2:SUITE 221
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-6630
Practice Address - Country:US
Practice Address - Phone:207-973-9949
Practice Address - Fax:207-973-9555
Is Sole Proprietor?:No
Enumeration Date:2005-07-14
Last Update Date:2020-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDO2140207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA2403288000OtherKEYSTONE HEALTH PLAN EAST
PA1562320OtherCIGNA
PA1013050100001Medicaid
PA1736339OtherBLUE SHIELD
PA30025514OtherKMHP
PA7414717OtherAETNA PPO
PA1092089OtherAETNA HMO
PA30025514OtherKMHP
PA2403288000OtherKEYSTONE HEALTH PLAN EAST