Provider Demographics
NPI:1275589152
Name:JOHN A WALSH MD PA
Entity Type:Organization
Organization Name:JOHN A WALSH MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:WALSH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-328-0245
Mailing Address - Street 1:PO BOX 17021
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-4065
Mailing Address - Country:US
Mailing Address - Phone:386-302-5064
Mailing Address - Fax:386-302-5093
Practice Address - Street 1:14 OFFICE PARK DR STE 7
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32137-3830
Practice Address - Country:US
Practice Address - Phone:386-302-5064
Practice Address - Fax:386-302-5093
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-25
Last Update Date:2021-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME78805174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL110996800Medicaid
FLQ0466OtherMEDICARE
FLE35593Medicare UPIN
FLP00119721Medicare ID - Type UnspecifiedRAILROAD MEDICARE
FL268707100Medicaid