Healthcare Provider Details

I. General information

NPI: 1992714448
Provider Name (Legal Business Name): JONATHAN WALTUCK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1365 CLIFTON RD NE BLDG A INTERNAL MEDICINE/RHEUMATOLOGY SUITE 4100
ATLANTA GA
30322-1013
US

IV. Provider business mailing address

1365 CLIFTON RD NE BLDG A INTERNAL MEDICINE/RHEUMATOLOGY SUITE 4100
ATLANTA GA
30322-1013
US

V. Phone/Fax

Practice location:
  • Phone: 404-778-4366
  • Fax:
Mailing address:
  • Phone: 404-778-4366
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number037103
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: