Provider Demographics
NPI: | 1104832138 |
---|---|
Name: | WALSH, KENNETH A (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | KENNETH |
Middle Name: | A |
Last Name: | WALSH |
Suffix: | |
Gender: | M |
Credentials: | MD |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 325 PARK AVE |
Mailing Address - Street 2: | |
Mailing Address - City: | HUNTINGTON |
Mailing Address - State: | NY |
Mailing Address - Zip Code: | 11743-2779 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 631-351-3782 |
Mailing Address - Fax: | 631-351-3729 |
Practice Address - Street 1: | 325 PARK AVE |
Practice Address - Street 2: | |
Practice Address - City: | HUNTINGTON |
Practice Address - State: | NY |
Practice Address - Zip Code: | 11743-2779 |
Practice Address - Country: | US |
Practice Address - Phone: | 631-351-3782 |
Practice Address - Fax: | 631-351-3729 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-07-31 |
Last Update Date: | 2008-07-02 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
NY | 161747-1 | 207RC0000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207RC0000X | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
NY | 41D641 | Other | BLUE CROSS/ BLUE SHIELD |
NY | 00906670 | Medicaid | |
NY | CP087 | Other | OXFORD |
NY | 2595080 | Other | GHI |
NY | 2C4894 | Other | HEALTHNET |
NY | 2C4894 | Other | HEALTHNET |
NY | 2595080 | Other | GHI |