Healthcare Provider Details

I. General information

NPI: 1881674331
Provider Name (Legal Business Name): PETER THOMAS WALSH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/19/2006
Last Update Date: 05/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4102 PINION DR
U S A F ACADEMY CO
80840-2502
US

IV. Provider business mailing address

2327 RUSTY RIDGE CT
COLORADO SPRINGS CO
80921-2077
US

V. Phone/Fax

Practice location:
  • Phone: 719-333-5102
  • Fax:
Mailing address:
  • Phone: 719-472-0612
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083A0100X
TaxonomyAerospace Medicine Physician
License Number4301050903
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: