Provider Demographics
NPI:1023099751
Name:WATERMAN, PETER MILES (MD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:MILES
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:DEPT# 42065 PO BOX 650823
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75265
Mailing Address - Country:US
Mailing Address - Phone:469-998-7443
Mailing Address - Fax:469-649-0764
Practice Address - Street 1:2000 E SOUTHERN AVE
Practice Address - Street 2:STE 102
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-7510
Practice Address - Country:US
Practice Address - Phone:480-820-9141
Practice Address - Fax:480-820-3785
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2020-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ19293207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ358996Medicaid
AZ358996Medicaid
05WCHHN12Medicare ID - Type Unspecified