Healthcare Provider Details

I. General information

NPI: 1982819447
Provider Name (Legal Business Name): DOUGLAS M WALSH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 E MISSOURI AVE SUITE C-200
PHOENIX AZ
85014
US

IV. Provider business mailing address

12829 S WAKIAL LOOP
PHOENIX AZ
85044-4110
US

V. Phone/Fax

Practice location:
  • Phone: 602-476-0800
  • Fax:
Mailing address:
  • Phone: 480-275-8455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number36411
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: