1871596825 NPI number — DR. TIMOTHY JOHN WOLTER MD

Employer Identification Number (EIN)	:
Provider Organization Name (Legal Business Name)	:
Provider Last Name (Legal Name)	:	WOLTER
Provider First Name	:	TIMOTHY
Provider Middle Name	:	JOHN
Provider Name Prefix Text	:	DR.
Provider Name Suffix Text	:
Provider Credential Text	:	MD
Provider Gender Code	:	M

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Provider Other Last Name	:
Provider Other First Name	:
Provider Other Middle Name	:
Provider Other Name Prefix Text	:
Provider Other Name Suffix Text	:
Provider Other Credential Text	:
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NPI Number	:	1871596825
Entity Type Code	:	Individual
Replacement NPI	:
Last Update Date	:	09/28/2007
NPI Deactivation Reason Code	:
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Provider First Line Business Mailing Address	:	716 WEST COLUMBIA STREET
Provider Second Line Business Mailing Address	:
Provider Business Mailing Address City Name	:	CHIPPEWA FALLS
Provider Business Mailing Address State Name	:	WI
Provider Business Mailing Address Postal Code	:	54729
Provider Business Mailing Address Country Code	:	US
Provider Business Mailing Address Telephone Number	:	7157261963
Provider Business Mailing Address Fax Number	:

Provider First Line Business Practice Location Address	:	716 W COLUMBIA ST
Provider Second Line Business Practice Location Address	:
Provider Business Practice Location Address City Name	:	CHIPPEWA FALLS
Provider Business Practice Location Address State Name	:	WI
Provider Business Practice Location Address Postal Code	:	547292104
Provider Business Practice Location Address Country Code	:	US
Provider Business Practice Location Address Telephone Number	:	7157261963
Provider Business Practice Location Address Fax Number	:
Provider Enumeration Date	:	05/23/2005

Authorized Official Last Name	:
Authorized Official First Name	:
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• Taxonomy code: 207Q00000X , with the licence number:  26902 , registered in the state of WI .

• Identifier: 30683800 , issued by the state of ( WI ) . This identifiers is of the category "".
• Identifier: B57712 , issued by the state of ( WI ) . This identifiers is of the category "".