Provider Demographics
NPI:1093703811
Name:WOLTHUIS, JOHN S (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:S
Last Name:WOLTHUIS
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 1:4650 HARRISON BLVD
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-4303
Mailing Address - Country:US
Mailing Address - Phone:801-475-3000
Mailing Address - Fax:801-475-3001
Practice Address - Street 1:4700 HARRISON BLVD
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-4303
Practice Address - Country:US
Practice Address - Phone:801-475-3000
Practice Address - Fax:801-475-3001
Is Sole Proprietor?:No
Enumeration Date:2005-10-06
Last Update Date:2011-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1756271205208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTC63349Medicare UPIN