Healthcare Provider Details

I. General information

NPI: 1225458144
Provider Name (Legal Business Name): KENNETH PETER WALSH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2014
Last Update Date: 09/17/2026
Certification Date: 01/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 ESSEX STREET SUITE 102
HACKENSACK NJ
07601
US

IV. Provider business mailing address

211 ESSEX STREET SUITE 102
HACKENSACK NJ
07601
US

V. Phone/Fax

Practice location:
  • Phone: 201-487-8882
  • Fax: 201-487-0943
Mailing address:
  • Phone: 201-487-8882
  • Fax: 201-487-0943

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberMD-54007
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number25MA1284700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: