Healthcare Provider Details

I. General information

NPI: 1518926179
Provider Name (Legal Business Name): JOHN RANDALL WALTZ MPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2006
Last Update Date: 04/02/2024
Certification Date: 04/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4025 SAN FELIPE RD 100
SAN JOSE CA
95135-1748
US

IV. Provider business mailing address

4205 SAN FELIPE RD STE 100
SAN JOSE CA
95135-1546
US

V. Phone/Fax

Practice location:
  • Phone: 408-238-1552
  • Fax: 408-238-1552
Mailing address:
  • Phone: 408-841-7203
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number25760
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: