Provider Demographics
NPI:1376500454
Name:WALZAK, DORIS ELAINE (MD)
Entity Type:Individual
Prefix:
First Name:DORIS
Middle Name:ELAINE
Last Name:WALZAK
Suffix:
Gender:F
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:PO BOX 183103
Mailing Address - Street 2:660 ACKERMAN 3RD FLOOR
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43218-3103
Mailing Address - Country:US
Mailing Address - Phone:614-293-2150
Mailing Address - Fax:614-293-6479
Practice Address - Street 1:456 WEST TENTH AVENUE
Practice Address - Street 2:CLINIC 3A 3D
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43210
Practice Address - Country:US
Practice Address - Phone:614-293-8105
Practice Address - Fax:614-293-4890
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35038032W207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0328792Medicaid
WA4117574Medicare ID - Type Unspecified
OH0328792Medicaid