Provider Demographics
NPI:1932271541
Name:WALSH, JOHN ALAN (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:ALAN
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 1:14 OFFICE PARK DR STE 7
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32137-3830
Mailing Address - Country:US
Mailing Address - Phone:386-302-5064
Mailing Address - Fax:386-302-5093
Practice Address - Street 1:14 OFFICE PARK DR STE 7
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32137-3830
Practice Address - Country:US
Practice Address - Phone:386-302-5064
Practice Address - Fax:386-302-5093
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2021-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME788052086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL225976OtherHEALTHEASE MEDICAID
FLP00119721OtherRAILROAD MEDICARE
Q0466OtherMEDICARE
FL111087700Medicaid
FL47143Medicare ID - Type Unspecified
FL47143YMedicare PIN