Provider Demographics
NPI:1114192390
Name:WALSH MEDICAL GROUP,A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:WALSH MEDICAL GROUP,A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LINDSAY
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-502-1144
Mailing Address - Street 1:947 S ANAHEIM BLVD STE 115
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92805-5582
Mailing Address - Country:US
Mailing Address - Phone:714-533-7320
Mailing Address - Fax:714-533-7321
Practice Address - Street 1:947 S ANAHEIM BLVD STE 115
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92805-5582
Practice Address - Country:US
Practice Address - Phone:714-533-7320
Practice Address - Fax:714-533-7321
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WALSH MEDICAL GROUP, A PROFESSIONAL CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-04-28
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
208000000X, 305S00000X
CA00A325660305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A325660OtherMEDI-CAL