Provider Demographics
NPI:1982819447
Name:WALSH, DOUGLAS M (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:M
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 1:12829 S WAKIAL LOOP
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85044-4110
Mailing Address - Country:US
Mailing Address - Phone:480-275-8455
Mailing Address - Fax:
Practice Address - Street 1:1400 E MISSOURI AVE
Practice Address - Street 2:SUITE C-200
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85014
Practice Address - Country:US
Practice Address - Phone:602-476-0800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ36411208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics