Provider Demographics
NPI:1982684643
Name:WALSH, JOHN W (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:W
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 1:5300 ELLIOTT DR
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-8632
Mailing Address - Country:US
Mailing Address - Phone:734-434-6262
Mailing Address - Fax:734-712-2820
Practice Address - Street 1:5300 ELLIOTT DR
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-8632
Practice Address - Country:US
Practice Address - Phone:734-434-6262
Practice Address - Fax:734-712-2820
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2010-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI056299207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0811009OtherBCBS INDIVIDUAL
MI1777972001OtherCIGNA
MI014990OtherMIDWEST HEALTH PLAN
MI0H14989OtherBCBS GROUP
MI100005954OtherMEDICARE RAILROAD PTAN
MI4403997OtherAETNA
MI2919708Medicaid
MI2919708Medicaid
MI0M86730005Medicare PIN
MI0M86720005Medicare PIN