Provider Demographics
NPI:1588615140
Name:WALTZ, KATHLEEN M (DO)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:M
Last Name:WALTZ
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2100 POWELL ST
Mailing Address - Street 2:SUITE 900
Mailing Address - City:EMERYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94608-1826
Mailing Address - Country:US
Mailing Address - Phone:510-350-2660
Mailing Address - Fax:510-879-9100
Practice Address - Street 1:1401 S GRAND AVE
Practice Address - Street 2:EMERGENCY DEPARTMENT
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90015-3010
Practice Address - Country:US
Practice Address - Phone:213-748-2411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA2)A7331207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX73310Medicaid
CAW20A7331EMedicare PIN
CAH19162Medicare UPIN