Provider Demographics
NPI:1417998295
Name:WALSTAD, JOE (MD)
Entity Type:Individual
Prefix:
First Name:JOE
Middle Name:
Last Name:WALSTAD
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:PO BOX 932353
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31193-2353
Mailing Address - Country:US
Mailing Address - Phone:800-443-3643
Mailing Address - Fax:865-560-7310
Practice Address - Street 1:501 REDMOND RD NW
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-1415
Practice Address - Country:US
Practice Address - Phone:706-291-0291
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2008-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA021369207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000259773GMedicaid
D31234Medicare UPIN
GA000259773GMedicaid