Provider Demographics
NPI:1114142254
Name:WALTZ, KAREN MARIE (MD)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:MARIE
Last Name:WALTZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:69 BROOKVIEW DRIVE
Mailing Address - Street 2:
Mailing Address - City:LITITZ
Mailing Address - State:PA
Mailing Address - Zip Code:17543
Mailing Address - Country:US
Mailing Address - Phone:717-741-3761
Mailing Address - Fax:
Practice Address - Street 1:1934 SECURITY DRIVE
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17402
Practice Address - Country:US
Practice Address - Phone:717-741-3761
Practice Address - Fax:717-741-9495
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD061740L207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA133197OtherBLUE SHIELD LEGACY NUMBER
G59881Medicare UPIN
PA133197OtherBLUE SHIELD LEGACY NUMBER