Provider Demographics
NPI:1346215613
Name:WALSH, MARK J (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:J
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 1:75 SYLVANIA DR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45440-3237
Mailing Address - Country:US
Mailing Address - Phone:937-320-5050
Mailing Address - Fax:937-320-5060
Practice Address - Street 1:75 SYLVANIA DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45440-3237
Practice Address - Country:US
Practice Address - Phone:937-320-5050
Practice Address - Fax:937-320-5060
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35051048207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0710781OtherMEDICARE PTAN
OH0856248Medicaid
OH0856248Medicaid
OHF18984Medicare UPIN