Healthcare Provider Details

I. General information

NPI: 1912132044
Provider Name (Legal Business Name): MR. CLEVELAND WILTZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2009
Last Update Date: 05/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

162 DODD BLVD STE 100
LANGLEY AFB VA
23665-1916
US

IV. Provider business mailing address

813 HAMDER WAY
NEWPORT NEWS VA
23602-9607
US

V. Phone/Fax

Practice location:
  • Phone: 757-764-1299
  • Fax: 757-225-9941
Mailing address:
  • Phone: 757-890-0593
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: