Provider Demographics
NPI:1578887519
Name:WALSTON, STEPHEN LOUIS (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:LOUIS
Last Name:WALSTON
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 25608
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84125-0608
Mailing Address - Country:US
Mailing Address - Phone:206-320-4476
Mailing Address - Fax:206-568-7043
Practice Address - Street 1:3236 78TH AVE SE STE 200
Practice Address - Street 2:
Practice Address - City:MERCER ISLAND
Practice Address - State:WA
Practice Address - Zip Code:98040-3500
Practice Address - Country:US
Practice Address - Phone:206-386-9500
Practice Address - Fax:206-386-9605
Is Sole Proprietor?:No
Enumeration Date:2010-03-19
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60423761207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1578887519Medicaid
WA2022131Medicaid