Provider Demographics
NPI:1881674331
Name:WALSH, PETER THOMAS (MD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:THOMAS
Last Name:WALSH
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 1:2327 RUSTY RIDGE CT
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80921-2077
Mailing Address - Country:US
Mailing Address - Phone:719-472-0612
Mailing Address - Fax:
Practice Address - Street 1:4102 PINION DR
Practice Address - Street 2:
Practice Address - City:U S A F ACADEMY
Practice Address - State:CO
Practice Address - Zip Code:80840-2502
Practice Address - Country:US
Practice Address - Phone:719-333-5102
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-19
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010509032083A0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083A0100XAllopathic & Osteopathic PhysiciansPreventive MedicineAerospace Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
809283Medicare PIN