Provider Demographics
NPI:1518926179
Name:WALTZ, JOHN RANDALL (MPT)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:RANDALL
Last Name:WALTZ
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4205 SAN FELIPE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95135-1546
Mailing Address - Country:US
Mailing Address - Phone:408-841-7203
Mailing Address - Fax:
Practice Address - Street 1:4025 SAN FELIPE RD
Practice Address - Street 2:100
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95135-1748
Practice Address - Country:US
Practice Address - Phone:408-238-1552
Practice Address - Fax:408-238-1552
Is Sole Proprietor?:No
Enumeration Date:2006-03-22
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA25760225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PT257600Medicare PIN