MEDICARE: JOHN WAELTZ M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207V00000X	Obstetrics & Gynecology Physician	26524	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1174638621
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN WAELTZ M.D.

Provider Business Mailing Address
First Line	:	4655 N PORT WASHINGTON RD
Second Line	:	SUITE 100
City	:	GLENDALE
State	:	WI
Zip	:	53212-1004
Country	:	US
Telephone Number	:	414-961-7444
Fax Number	:	414-961-7445

Provider Business Practice Location Address
First Line	:	4655 N PORT WASHINGTON RD
Second Line	:	SUITE 100
City	:	GLENDALE
State	:	WI
Zip	:	53212-1004
Country	:	US
Telephone Number	:	414-961-7444
Fax Number	:	414-961-7445

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/21/2006
Last Update Date	:	10/31/2008

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