Provider Demographics
NPI:1740274760
Name:WALSH, CHANTAL G (MD)
Entity type:Individual
Prefix:DR
First Name:CHANTAL
Middle Name:G
Last Name:WALSH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1450 COLUMBUS AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON COURT HOUSE
Mailing Address - State:OH
Mailing Address - Zip Code:43160-3701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1510 COLUMBUS AVE STE 230
Practice Address - Street 2:
Practice Address - City:WASHINGTON COURT HOUSE
Practice Address - State:OH
Practice Address - Zip Code:43160-1987
Practice Address - Country:US
Practice Address - Phone:740-333-3177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-06
Last Update Date:2014-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35074904207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2255885Medicaid
OH2255885Medicaid
OHH175890Medicare PIN