MEDICARE: DAVID A WALETZKO MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	36750	MN

General Provider Information

NPI Number	:	1851342745
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAVID A WALETZKO MD

Provider Business Mailing Address
First Line	:	911 NORTHLAND DR
Second Line	:
City	:	PRINCETON
State	:	MN
Zip	:	55371-2172
Country	:	US
Telephone Number	:	763-389-1313
Fax Number	:

Provider Business Practice Location Address
First Line	:	911 NORTHLAND DR
Second Line	:
City	:	PRINCETON
State	:	MN
Zip	:	55371-2172
Country	:	US
Telephone Number	:	763-389-1313
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/15/2006
Last Update Date	:	01/17/2014

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