=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225088362
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN E. WALZ MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/11/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1511 PARK AVE
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53925-2401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-623-3040
-----------------------------------------------------
Fax | 920-623-2244
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 370
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53925-0370
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-623-3040
-----------------------------------------------------
Fax | 920-623-2244
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 21885
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------