Provider Demographics
NPI:1376989202
Name:WOLTJER, THOMAS ALLEN (DO)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:ALLEN
Last Name:WOLTJER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 N LORRAINE AVE
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67214-4837
Mailing Address - Country:US
Mailing Address - Phone:316-683-5611
Mailing Address - Fax:316-683-0294
Practice Address - Street 1:530 N LORRAINE AVE
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67214-4837
Practice Address - Country:US
Practice Address - Phone:316-683-5611
Practice Address - Fax:316-683-0294
Is Sole Proprietor?:No
Enumeration Date:2013-05-19
Last Update Date:2024-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS05-42080207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS201252990AMedicaid