Healthcare Provider Details

I. General information

NPI: 1699747246
Provider Name (Legal Business Name): MARY P WALSH DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2006
Last Update Date: 10/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43 SOKOKIS TRAIL
EAST WATERBORO ME
04030
US

IV. Provider business mailing address

PO BOX 1849
LEWISTON ME
04241-1849
US

V. Phone/Fax

Practice location:
  • Phone: 207-247-6742
  • Fax: 207-247-6114
Mailing address:
  • Phone: 207-784-2554
  • Fax: 207-777-5363

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number1532
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: