Provider Demographics
NPI:1306020664
Name:WALSHAUSER, MARK ANDREW (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ANDREW
Last Name:WALSHAUSER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 25228
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62525-5228
Mailing Address - Country:US
Mailing Address - Phone:217-329-3232
Mailing Address - Fax:217-233-1670
Practice Address - Street 1:321 REGENCY PARK STE 100
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-1887
Practice Address - Country:US
Practice Address - Phone:618-416-7970
Practice Address - Fax:618-416-7971
Is Sole Proprietor?:No
Enumeration Date:2007-12-21
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2010024540207R00000X
IL036128331207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036128331Medicaid