Provider Demographics
NPI:1649920760
Name:WALSH, JOHN JAMES (MD-PHD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:JAMES
Last Name:WALSH
Suffix:
Gender:M
Credentials:MD-PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:670 ELLSWORTH AVE
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-1636
Mailing Address - Country:US
Mailing Address - Phone:941-538-8091
Mailing Address - Fax:
Practice Address - Street 1:56 FRANKLIN ST STE 1
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06706-1281
Practice Address - Country:US
Practice Address - Phone:203-709-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-24
Last Update Date:2022-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT06-0646844390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program