Provider Demographics
NPI:1447245535
Name:WATERTON, SELWYN (MD)
Entity type:Individual
Prefix:
First Name:SELWYN
Middle Name:
Last Name:WATERTON
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 1:201 E. SAMPLE ROAD
Mailing Address - Street 2:DEPT OF EMERGENCY MEDICINE
Mailing Address - City:DEERFIELD BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33064
Mailing Address - Country:US
Mailing Address - Phone:954-786-6800
Mailing Address - Fax:
Practice Address - Street 1:201 E. SAMPLE ROAD
Practice Address - Street 2:DEPT OF EMERGENCY MEDICINE
Practice Address - City:DEERFIELD BEACH
Practice Address - State:FL
Practice Address - Zip Code:33064
Practice Address - Country:US
Practice Address - Phone:954-786-6800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-14
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY195018-1207P00000X
FLME 97308207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01720378Medicaid
NY588741Medicare ID - Type Unspecified