Provider Demographics
NPI:1720078900
Name:WALZ, BRENT MICHAEL (MD)
Entity type:Individual
Prefix:DR
First Name:BRENT
Middle Name:MICHAEL
Last Name:WALZ
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 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-3704
Mailing Address - Country:US
Mailing Address - Phone:502-559-9337
Mailing Address - Fax:502-272-5339
Practice Address - Street 1:1220 SPRING ST
Practice Address - Street 2:
Practice Address - City:JEFFERSONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47130-3704
Practice Address - Country:US
Practice Address - Phone:812-282-8494
Practice Address - Fax:812-280-3030
Is Sole Proprietor?:No
Enumeration Date:2005-10-27
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY39291207X00000X
IN01060263A207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200354700AMedicaid
IN000000365692OtherIN BC
KY7100620820Medicaid
ININ2570009OtherMEDICARE
IN1720078900OtherNPI
I30007Medicare UPIN