Basic Information
| Provider Information | |||||||||
| NPI: | 1467414383 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALSH | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | W. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10058 S YACHT CLUB DR | ||||||||
| Address2: | |||||||||
| City: | TREASURE ISLAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337063102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7273609581 | ||||||||
| FaxNumber: | 8443055954 | ||||||||
| Practice Location | |||||||||
| Address1: | 560 JACKSON ST N | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337051449 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7273291600 | ||||||||
| FaxNumber: | 7273291694 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2006 | ||||||||
| LastUpdateDate: | 01/04/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | ME45984 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 63295300 | 05 | FL | MEDICAID |