Provider Demographics
NPI:1982055083
Name:WAELTZ, THOMAS JONATHAN (OD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:JONATHAN
Last Name:WAELTZ
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4773 N CRAMER ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53211-1228
Mailing Address - Country:US
Mailing Address - Phone:414-339-4265
Mailing Address - Fax:
Practice Address - Street 1:3051 CAHILL MAIN
Practice Address - Street 2:
Practice Address - City:FITCHBURG
Practice Address - State:WI
Practice Address - Zip Code:53711-7109
Practice Address - Country:US
Practice Address - Phone:608-661-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-29
Last Update Date:2018-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3421-35152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist