Provider Demographics
NPI:1609026608
Name:LANCE PATRICK WALSH MD PHD A PROFESSIONAL MEDICAL CORPORATION
Entity Type:Organization
Organization Name:LANCE PATRICK WALSH MD PHD A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LANCE
Authorized Official - Middle Name:P
Authorized Official - Last Name:WALSH
Authorized Official - Suffix:
Authorized Official - Credentials:MD PHD
Authorized Official - Phone:760-346-7191
Mailing Address - Street 1:2201 NORTH JEFFERSON AVENUE
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:TX
Mailing Address - Zip Code:75455-2338
Mailing Address - Country:US
Mailing Address - Phone:903-577-6000
Mailing Address - Fax:
Practice Address - Street 1:72057 HIGHWAY 111
Practice Address - Street 2:
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-4927
Practice Address - Country:US
Practice Address - Phone:760-346-7191
Practice Address - Fax:760-346-7905
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-25
Last Update Date:2019-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA98108208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty