Provider Demographics
NPI:1992714448
Name:WALTUCK, JONATHAN (MD)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:WALTUCK
Suffix:
Gender:M
Credentials:MD
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1365 CLIFTON RD NE BLDG A
Mailing Address - Street 2:INTERNAL MEDICINE/RHEUMATOLOGY SUITE 4100
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30322-1013
Mailing Address - Country:US
Mailing Address - Phone:404-778-4366
Mailing Address - Fax:
Practice Address - Street 1:1365 CLIFTON RD NE BLDG A
Practice Address - Street 2:INTERNAL MEDICINE/RHEUMATOLOGY SUITE 4100
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30322-1013
Practice Address - Country:US
Practice Address - Phone:404-778-4366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA037103207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAE69835Medicare UPIN