Provider Demographics
NPI:1720151814
Name:WALTZ, GARY W (MD)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:W
Last Name:WALTZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 E BROAD ST
Mailing Address - Street 2:11TH FLOOR
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43215-3414
Mailing Address - Country:US
Mailing Address - Phone:614-466-6583
Mailing Address - Fax:614-644-5331
Practice Address - Street 1:157 W CEDAR ST
Practice Address - Street 2:B-3
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44307-2564
Practice Address - Country:US
Practice Address - Phone:330-434-2062
Practice Address - Fax:330-434-0783
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-0440192084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0566725Medicare ID - Type Unspecified