Provider Demographics
NPI:1104275528
Name:WALTZ, JEFFREY (MD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:WALTZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 85378
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60689-5378
Mailing Address - Country:US
Mailing Address - Phone:336-274-6682
Mailing Address - Fax:336-274-8097
Practice Address - Street 1:171 ASHLEY AVE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29425-4444
Practice Address - Country:US
Practice Address - Phone:843-792-6200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-07
Last Update Date:2025-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC396692085R0202X
SCLL396692085R0202X
NC2021-027702085R0202X
VA01012733842085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC396690Medicaid