Provider Demographics
NPI:1033131883
Name:WALSH, JOHN STEPHEN (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:STEPHEN
Last Name:WALSH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:313 SW PINE ISLAND RD
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33991-2043
Mailing Address - Country:US
Mailing Address - Phone:239-458-6755
Mailing Address - Fax:
Practice Address - Street 1:313 SW PINE ISLAND RD
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33991-2043
Practice Address - Country:US
Practice Address - Phone:239-458-6755
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2025-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY210572207Q00000X
MA274001207Q00000X
FLME145947207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01871796Medicaid
G79912Medicare UPIN
NY01871796Medicaid