Provider Demographics
NPI:1407021421
Name:WALSH MEDICAL GROUP, A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:WALSH MEDICAL GROUP, A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LINDSAY
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-502-1144
Mailing Address - Street 1:1110 W LA PALMA AVE
Mailing Address - Street 2:SUITE 6
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92801-2821
Mailing Address - Country:US
Mailing Address - Phone:714-956-5656
Mailing Address - Fax:714-502-1146
Practice Address - Street 1:1110 W LA PALMA AVE STE 6
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92801-2823
Practice Address - Country:US
Practice Address - Phone:714-502-1144
Practice Address - Fax:714-502-1146
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WALSH MEDICAL GROUP, A PROFESSIONAL CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-04-30
Last Update Date:2020-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00A325660305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A325660OtherMEDI-CAL