Basic Information
| Provider Information | |||||||||
| NPI: | 1588082200 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BALTZ | ||||||||
| FirstName: | JULIA | ||||||||
| MiddleName: | O. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 415348 | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022415348 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002258885 | ||||||||
| FaxNumber: | 5083348105 | ||||||||
| Practice Location | |||||||||
| Address1: | 1672 S COUNTY TRL STE 101 | ||||||||
| Address2: | |||||||||
| City: | EAST GREENWICH | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028185099 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4018857546 | ||||||||
| FaxNumber: | 4018856640 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2014 | ||||||||
| LastUpdateDate: | 11/16/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ND0101X | 16273 | RI | N | Allopathic & Osteopathic Physicians | Dermatology | MOHS-Micrographic Surgery | 207N00000X | 275273 | MA | Y | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 110115620A | 05 | MA | MEDICAID |