Provider Demographics
NPI:1033131883
Name:WALSH, JOHN STEPHEN (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:STEPHEN
Last Name:WALSH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:369 EAST MAIN STREET
Mailing Address - Street 2:SUITE 3
Mailing Address - City:EAST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11730
Mailing Address - Country:US
Mailing Address - Phone:631-381-4500
Mailing Address - Fax:631-581-5905
Practice Address - Street 1:369 EAST MAIN STREET
Practice Address - Street 2:SUITE 3
Practice Address - City:EAST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11730
Practice Address - Country:US
Practice Address - Phone:631-381-4500
Practice Address - Fax:631-581-5905
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY210572207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01871796Medicaid
G79912Medicare UPIN
NY01871796Medicaid