Provider Demographics
NPI:1093770919
Name:WALTUCH, JEAN KARYN (MD)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:KARYN
Last Name:WALTUCH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JEANIE
Other - Middle Name:K
Other - Last Name:WALTUCH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1300 CRANE ST
Mailing Address - Street 2:
Mailing Address - City:MENLO PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94025-4260
Mailing Address - Country:US
Mailing Address - Phone:650-498-6500
Mailing Address - Fax:
Practice Address - Street 1:1300 CRANE ST
Practice Address - Street 2:
Practice Address - City:MENLO PARK
Practice Address - State:CA
Practice Address - Zip Code:94025-4260
Practice Address - Country:US
Practice Address - Phone:650-498-6500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA60642207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MMM00087MOtherNHIC
00A606420Medicare ID - Type Unspecified
G91590Medicare UPIN