Provider Demographics
NPI:1174638621
Name:WAELTZ, JOHN (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:WAELTZ
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 1:4655 N PORT WASHINGTON RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53212-1004
Mailing Address - Country:US
Mailing Address - Phone:414-961-7444
Mailing Address - Fax:414-961-7445
Practice Address - Street 1:4655 N PORT WASHINGTON RD
Practice Address - Street 2:SUITE 100
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53212-1004
Practice Address - Country:US
Practice Address - Phone:414-961-7444
Practice Address - Fax:414-961-7445
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2008-10-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI26524207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30767800Medicaid
WI30767800Medicaid