Provider Demographics
NPI:1043341480
Name:PATRICK WALSH MD PROFESSIONAL ASSOCIATION
Entity type:Organization
Organization Name:PATRICK WALSH MD PROFESSIONAL ASSOCIATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:WALSH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-923-8220
Mailing Address - Street 1:1622 8TH AVE
Mailing Address - Street 2:120
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-4155
Mailing Address - Country:US
Mailing Address - Phone:817-923-8220
Mailing Address - Fax:817-923-9004
Practice Address - Street 1:1622 8TH AVE
Practice Address - Street 2:120
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4155
Practice Address - Country:US
Practice Address - Phone:817-923-8220
Practice Address - Fax:817-923-9004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2015-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH5814207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX153099001Medicaid
TX00094TMedicare PIN
TXDF4601Medicare PIN