Provider Demographics
NPI:1427042068
Name:WOLTJEN, JOHN ANTHONY (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ANTHONY
Last Name:WOLTJEN
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 1:100 NW MOCK AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BLUE SPRINGS
Mailing Address - State:MO
Mailing Address - Zip Code:64014-2501
Mailing Address - Country:US
Mailing Address - Phone:816-220-9080
Mailing Address - Fax:816-220-9010
Practice Address - Street 1:100 NW MOCK AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:BLUE SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:64014-2501
Practice Address - Country:US
Practice Address - Phone:816-220-9080
Practice Address - Fax:816-220-9010
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR4B13207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOAO1454Medicare UPIN
MO0008617Medicare ID - Type Unspecified