Provider Demographics
NPI:1497767396
Name:WOLTERBEEK, MICHAEL (DPM)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:WOLTERBEEK
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:609 E ORANGEBURG AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-5580
Mailing Address - Country:US
Mailing Address - Phone:209-572-3613
Mailing Address - Fax:209-572-4528
Practice Address - Street 1:609 E ORANGEBURG AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-5580
Practice Address - Country:US
Practice Address - Phone:209-572-3613
Practice Address - Fax:209-572-4528
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4215213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E42150Medicaid
CA000E42150Medicaid
CAU76032Medicare UPIN