Provider Demographics
NPI:1851343610
Name:WALSH, KAREN MARIE (DPM)
Entity Type:Individual
Prefix:DR
First Name:KAREN
Middle Name:MARIE
Last Name:WALSH
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:DR
Other - First Name:KAREN
Other - Middle Name:MARIE
Other - Last Name:KOZUB
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPM
Mailing Address - Street 1:1100 MICHIGAN AVE
Mailing Address - Street 2:SUITE D
Mailing Address - City:MARYSVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48040-2112
Mailing Address - Country:US
Mailing Address - Phone:810-364-6614
Mailing Address - Fax:810-364-6615
Practice Address - Street 1:1100 MICHIGAN AVE
Practice Address - Street 2:SUITE D
Practice Address - City:MARYSVILLE
Practice Address - State:MI
Practice Address - Zip Code:48040-2112
Practice Address - Country:US
Practice Address - Phone:810-364-6614
Practice Address - Fax:810-364-6615
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2013-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIKW001963213EP1101X, 213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4505540Medicaid
MI4795730001Medicare NSC
MIP32680001Medicare PIN
MI4505540Medicaid