Basic Information
| Provider Information | |||||||||
| NPI: | 1205908332 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JOHN F. WILTZ PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2801 JACKSON AVE | ||||||||
| Address2: | |||||||||
| City: | PT PLEASANT | ||||||||
| State: | WV | ||||||||
| PostalCode: | 255501713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3046754107 | ||||||||
| FaxNumber: | 3046754233 | ||||||||
| Practice Location | |||||||||
| Address1: | 2801 JACKSON AVE | ||||||||
| Address2: | |||||||||
| City: | PT PLEASANT | ||||||||
| State: | WV | ||||||||
| PostalCode: | 255501713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3046754107 | ||||||||
| FaxNumber: | 3046754233 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | WILTZ | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | F. | ||||||||
| AuthorizedOfficialTitleorPosition: | DOCTOR | ||||||||
| AuthorizedOfficialTelephone: | 3046754107 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 18090 | WV | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 0109733000 | 05 | WV | MEDICAID | 0189415 | 05 | OH | MEDICAID |