Basic Information
| Provider Information | |||||||||
| NPI: | 1588615140 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALTZ | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | M. | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2100 POWELL ST | ||||||||
| Address2: | SUITE 900 | ||||||||
| City: | EMERYVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946081826 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5103502660 | ||||||||
| FaxNumber: | 5108799100 | ||||||||
| Practice Location | |||||||||
| Address1: | 1401 S GRAND AVE | ||||||||
| Address2: | EMERGENCY DEPARTMENT | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900153010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2137482411 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2006 | ||||||||
| LastUpdateDate: | 11/16/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 2)A7331 | CA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00AX73310 | 05 | CA | MEDICAID |