Provider Demographics
NPI:1851373823
Name:WALSH, BRIAN JOHN (DO)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:JOHN
Last Name:WALSH
Suffix:
Gender:M
Credentials:DO
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 1297
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:DE
Mailing Address - Zip Code:19903-1297
Mailing Address - Country:US
Mailing Address - Phone:302-734-0400
Mailing Address - Fax:302-406-2914
Practice Address - Street 1:744 S WEBSTER AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-3505
Practice Address - Country:US
Practice Address - Phone:920-433-7451
Practice Address - Fax:920-433-7453
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC20003705207RP1001X
WI20955-875207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0000318903Medicaid
DE0000318903Medicaid
DE000C91D73Medicare PIN