Provider Demographics
NPI:1699718809
Name:WATERMAN, BRADLEY J (MD)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:J
Last Name:WATERMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2965 W 3500 S
Mailing Address - Street 2:
Mailing Address - City:WEST VALLEY CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84119-3602
Mailing Address - Country:US
Mailing Address - Phone:801-965-3600
Mailing Address - Fax:
Practice Address - Street 1:24 S 1100 E STE 105
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-1593
Practice Address - Country:US
Practice Address - Phone:801-965-3600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-14
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI46318208800000X
UT6602968-1205208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology