Provider Demographics
NPI:1265473813
Name:WALSH, MARK D (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:D
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 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8603
Mailing Address - Fax:
Practice Address - Street 1:300 W FRONT ST
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:SC
Practice Address - Zip Code:29657-1012
Practice Address - Country:US
Practice Address - Phone:864-843-5605
Practice Address - Fax:864-843-0996
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-08
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC20774207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC080145957OtherRR MEDICARE
SC207742Medicaid
G91630Medicare UPIN
SC6315Medicare PIN
4542Medicare PIN