Provider Demographics
NPI:1720355159
Name:J ANTHONY WOLTJEN, MD, PC
Entity Type:Organization
Organization Name:J ANTHONY WOLTJEN, MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:WOLTJEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:816-220-9080
Mailing Address - Street 1:100 NW MOCK AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BLUE SPRINGS
Mailing Address - State:MO
Mailing Address - Zip Code:64014-2501
Mailing Address - Country:US
Mailing Address - Phone:816-220-9080
Mailing Address - Fax:816-220-9010
Practice Address - Street 1:100 NW MOCK AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:BLUE SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:64014-2501
Practice Address - Country:US
Practice Address - Phone:816-220-9080
Practice Address - Fax:816-220-9010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-30
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR4B13174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0008617OtherPTAN
A01454Medicare UPIN