Provider Demographics
NPI:1184644254
Name:WILTZ, DANIEL JOSEPH (MD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:JOSEPH
Last Name:WILTZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:111 COACHMAN DR
Mailing Address - Street 2:J
Mailing Address - City:YOUNGSVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70592-5239
Mailing Address - Country:US
Mailing Address - Phone:337-839-0177
Mailing Address - Fax:
Practice Address - Street 1:1117 N MAIN ST
Practice Address - Street 2:SUITE B
Practice Address - City:SAINT MARTINVILLE
Practice Address - State:LA
Practice Address - Zip Code:70582-3513
Practice Address - Country:US
Practice Address - Phone:337-394-7111
Practice Address - Fax:337-394-8105
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2019-02-10
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
LA023274207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1493465Medicaid
LAG66007Medicare UPIN
LA1493465Medicaid