Provider Demographics
NPI:1003952318
Name:WALSH, MARK KIM (MD,PHD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:KIM
Last Name:WALSH
Suffix:
Gender:M
Credentials:MD,PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6561 E. CARONDELET DR.
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85710-2161
Mailing Address - Country:US
Mailing Address - Phone:520-886-2597
Mailing Address - Fax:520-886-6639
Practice Address - Street 1:6561 E. CARONDELET DR.
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85710-2161
Practice Address - Country:US
Practice Address - Phone:520-886-2597
Practice Address - Fax:520-886-6639
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2017-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ41270207WX0107X
MI4301089446207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ438790Medicaid
AZZ130084Medicare PIN
AZZ130084Medicare PIN