Healthcare Provider Details

I. General information

NPI: 1427323518
Provider Name (Legal Business Name): MARNIE WAGNER WALSTON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2012
Last Update Date: 11/23/2020
Certification Date: 11/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 PERKINS SQ
AKRON OH
44308-1063
US

IV. Provider business mailing address

1 PERKINS SQ
AKRON OH
44308-1063
US

V. Phone/Fax

Practice location:
  • Phone: 330-543-8530
  • Fax: 330-543-3731
Mailing address:
  • Phone: 330-543-8530
  • Fax: 330-543-3731

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35122993
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: