MEDICARE: DR. KENNETH BRIAN WALTZER 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	207RG0300X	Geriatric Medicine (Internal Medicine) Physician	A45950	CA

General Provider Information

NPI Number	:	1437424090
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KENNETH BRIAN WALTZER M.D.

Provider Business Mailing Address
First Line	:	171 PIER AVE # 160
Second Line	:
City	:	SANTA MONICA
State	:	CA
Zip	:	90405-5311
Country	:	US
Telephone Number	:	424-228-2421
Fax Number	:

Provider Business Practice Location Address
First Line	:	171 PIER AVE # 160
Second Line	:
City	:	SANTA MONICA
State	:	CA
Zip	:	90405-5311
Country	:	US
Telephone Number	:	424-228-2421
Fax Number	:

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

Provider Enumeration Date	:	03/15/2012
Last Update Date	:	03/15/2012

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