Provider Demographics
NPI:1144316332
Name:WALSH, KEVIN C (MD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:C
Last Name:WALSH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 S 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-3550
Mailing Address - Country:US
Mailing Address - Phone:509-494-6700
Mailing Address - Fax:509-573-6275
Practice Address - Street 1:521 E MOUNTAIN VIEW AVE
Practice Address - Street 2:
Practice Address - City:ELLENSBURG
Practice Address - State:WA
Practice Address - Zip Code:98926-3865
Practice Address - Country:US
Practice Address - Phone:509-962-1414
Practice Address - Fax:509-962-1408
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2016-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00029530207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAGAB38059Medicare Oscar/Certification
080082993Medicare ID - Type UnspecifiedRR MEDICARE
WA8935318OtherCRIME VICTIMS
GAB15597Medicare ID - Type Unspecified
WAWA5864OtherREGENCE
911019392OtherCOMMERCIAL
WA80286OtherL & I
WA8138943OtherCHPW
WA8138943Medicaid
F28996Medicare UPIN