Provider Demographics
NPI:1750551420
Name:WALSH, ALEXANDRA M (MD)
Entity type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:M
Last Name:WALSH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ALEXANDRA
Other - Middle Name:MARIA
Other - Last Name:DICKERMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3200 E CAMELBACK RD
Mailing Address - Street 2:STE 250
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85018-2311
Mailing Address - Country:US
Mailing Address - Phone:602-933-1814
Mailing Address - Fax:
Practice Address - Street 1:1919 E THOMAS RD
Practice Address - Street 2:AMBULATORY BLDG
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-7710
Practice Address - Country:US
Practice Address - Phone:602-933-0920
Practice Address - Fax:602-933-2492
Is Sole Proprietor?:No
Enumeration Date:2008-03-09
Last Update Date:2018-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ52881208000000X, 2080P0207X
AL288642080P0207X
NV138162080P0207X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-Oncology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ625103Medicaid
NV1794745Medicaid