Provider Demographics
NPI:1174533558
Name:MALETZ, WILLARD L (MD)
Entity type:Individual
Prefix:DR
First Name:WILLARD
Middle Name:L
Last Name:MALETZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 52
Mailing Address - Street 2:
Mailing Address - City:SEAL BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90740-0052
Mailing Address - Country:US
Mailing Address - Phone:562-989-6457
Mailing Address - Fax:866-617-4477
Practice Address - Street 1:3939 ATLANTIC AVE
Practice Address - Street 2:SUITE 205
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90807-3536
Practice Address - Country:US
Practice Address - Phone:562-989-6457
Practice Address - Fax:562-989-6661
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2012-11-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG061263207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G61263Medicaid
CA00G61263Medicaid
CAF15952Medicare UPIN
G61263Medicare ID - Type Unspecified