Provider Demographics
NPI:1205985561
Name:WAYTUK, JOHN P (DO)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:P
Last Name:WAYTUK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4119 E SELLS DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85018-4253
Mailing Address - Country:US
Mailing Address - Phone:602-430-8910
Mailing Address - Fax:
Practice Address - Street 1:450 S OCOTILLO AVE
Practice Address - Street 2:
Practice Address - City:BENSON
Practice Address - State:AZ
Practice Address - Zip Code:85602-6403
Practice Address - Country:US
Practice Address - Phone:520-586-2261
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2855207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ150102Medicaid
AZA67771Medicare UPIN