Provider Demographics
NPI:1225088362
Name:WALZ, JOHN E (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:E
Last Name:WALZ
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:PO BOX 370
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:WI
Mailing Address - Zip Code:53925-0370
Mailing Address - Country:US
Mailing Address - Phone:920-623-3040
Mailing Address - Fax:920-623-2244
Practice Address - Street 1:1511 PARK AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:WI
Practice Address - Zip Code:53925-2401
Practice Address - Country:US
Practice Address - Phone:920-623-3040
Practice Address - Fax:920-623-2244
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI21885174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI391415680-00OtherUNITY HEALTH PLAN
WI1005999OtherPHYSICIANS PLUS
WI30477200Medicaid
WI391415680019OtherBLUE CROSS
WI391415680-01OtherHERITAGE/JOHN DEERE
WI538607OtherDEAN HEALTH PLAN
WI13084Medicare ID - Type Unspecified
WI391415680-01OtherHERITAGE/JOHN DEERE