Basic Information
| Provider Information | |||||||||
| NPI: | 1518926179 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALTZ | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | RANDALL | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | MPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4205 SAN FELIPE RD | ||||||||
| Address2: | STE 100 | ||||||||
| City: | SAN JOSE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 951351546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4082381552 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4025 SAN FELIPE RD | ||||||||
| Address2: | 100 | ||||||||
| City: | SAN JOSE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 951351748 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4082381552 | ||||||||
| FaxNumber: | 4082381552 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2006 | ||||||||
| LastUpdateDate: | 09/18/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 25760 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.