Healthcare Provider Details

I. General information

NPI: 1396748364
Provider Name (Legal Business Name): JOEL STUART RETHOLTZ D.O..
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 02/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1103 VILLAGE SQUARE DR STE 100
PERRYSBURG OH
43551-1762
US

IV. Provider business mailing address

1103 VILLAGE SQUARE DR STE 100
PERRYSBURG OH
43551-1762
US

V. Phone/Fax

Practice location:
  • Phone: 419-872-3213
  • Fax: 419-872-9549
Mailing address:
  • Phone: 419-872-3213
  • Fax: 419-872-9549

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number34-00-2442
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: