Provider Demographics
NPI:1568405561
Name:WALTZ, KEVIN L (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:L
Last Name:WALTZ
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:8103 CLEARVISTA PKWY
Mailing Address - Street 2:SUITE 240
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46256-5628
Mailing Address - Country:US
Mailing Address - Phone:317-845-9488
Mailing Address - Fax:317-570-7433
Practice Address - Street 1:8103 CLEARVISTA PKWY
Practice Address - Street 2:SUITE 240
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46256-5628
Practice Address - Country:US
Practice Address - Phone:317-845-9488
Practice Address - Fax:317-570-7433
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN01041436A207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
INE22498Medicare UPIN
IN673150BMedicare ID - Type Unspecified