Provider Demographics
NPI:1144230210
Name:WALSH, JAMES PATRICK (OD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:PATRICK
Last Name:WALSH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2221 CHECKERBERRY LN
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62711-7203
Mailing Address - Country:US
Mailing Address - Phone:217-698-3426
Mailing Address - Fax:
Practice Address - Street 1:2300 W WHITE OAKS DR
Practice Address - Street 2:SAM'S CLUB OPTICAL
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-6423
Practice Address - Country:US
Practice Address - Phone:217-698-7662
Practice Address - Fax:217-698-7875
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2008-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-008528152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK51915Medicare PIN
ILU33760Medicare UPIN