MEDICARE: JONATHAN WALTUCK M.D.

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	207RR0500X	Rheumatology Physician	037103	GA

General Provider Information

NPI Number	:	1992714448
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JONATHAN WALTUCK M.D.

Provider Business Mailing Address
First Line	:	1365 CLIFTON RD NE BLDG A
Second Line	:	INTERNAL MEDICINE/RHEUMATOLOGY SUITE 4100
City	:	ATLANTA
State	:	GA
Zip	:	30322-1013
Country	:	US
Telephone Number	:	404-778-4366
Fax Number	:

Provider Business Practice Location Address
First Line	:	1365 CLIFTON RD NE BLDG A
Second Line	:	INTERNAL MEDICINE/RHEUMATOLOGY SUITE 4100
City	:	ATLANTA
State	:	GA
Zip	:	30322-1013
Country	:	US
Telephone Number	:	404-778-4366
Fax Number	:

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

Provider Enumeration Date	:	08/05/2006
Last Update Date	:	07/08/2007

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