Provider Demographics
NPI:1821198904
Name:WIRTZ, JOHN VICTOR (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:VICTOR
Last Name:WIRTZ
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:PO BOX 74696
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44194-0779
Mailing Address - Country:US
Mailing Address - Phone:216-383-6480
Mailing Address - Fax:216-383-6745
Practice Address - Street 1:25651 DETROIT RD STE 304
Practice Address - Street 2:
Practice Address - City:WESTLAKE
Practice Address - State:OH
Practice Address - Zip Code:44145-2415
Practice Address - Country:US
Practice Address - Phone:216-383-0100
Practice Address - Fax:216-383-6481
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35065799W207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F84451Medicare UPIN