=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700528551
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DUSTY WALTZ DPM
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/12/2022
-----------------------------------------------------
Last Update Date | 06/23/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10122 E 10TH ST STE 210
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46229-2664
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-355-7356
-----------------------------------------------------
Fax | 317-806-1175
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6626 E 75TH ST STE 500
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46250-2890
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-621-7468
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number | 41000455A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number | 07001500A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------