Provider Demographics
NPI:1134747207
Name:WANTZ, JOSEPH DAVID
Entity type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:DAVID
Last Name:WANTZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:408 CORNICHE CT
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:MD
Mailing Address - Zip Code:21158-4449
Mailing Address - Country:US
Mailing Address - Phone:410-207-4209
Mailing Address - Fax:
Practice Address - Street 1:6500 RIGGS RD
Practice Address - Street 2:
Practice Address - City:HYATTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20783-3056
Practice Address - Country:US
Practice Address - Phone:301-559-0300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-06
Last Update Date:2020-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA5298225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1104Medicaid