Provider Demographics
NPI:1679544860
Name:WALSH, GREGORY ALLAN (DC)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:ALLAN
Last Name:WALSH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:851 CHICKADEE DR
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32127-4770
Mailing Address - Country:US
Mailing Address - Phone:386-761-4107
Mailing Address - Fax:
Practice Address - Street 1:545 W GRANADA BLVD
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-5103
Practice Address - Country:US
Practice Address - Phone:386-672-6243
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH6392111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL22635OtherBCBS
FL22635OtherBCBS
FLU16879Medicare UPIN