Provider Demographics
NPI:1548476195
Name:WALSH, ELLIOTT BLAIR (OD)
Entity type:Individual
Prefix:DR
First Name:ELLIOTT
Middle Name:BLAIR
Last Name:WALSH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1061 HARMON AVENUE STE 1D0
Mailing Address - Street 2:WINN ARMY COMMUNITY HOSPITAL-
Mailing Address - City:FORT STEWART
Mailing Address - State:GA
Mailing Address - Zip Code:31314-5611
Mailing Address - Country:US
Mailing Address - Phone:912-435-5696
Mailing Address - Fax:
Practice Address - Street 1:WINN ARMY COMMUNITY HOSPITAL - 1061 HARMON AVE
Practice Address - Street 2:STE 1D03
Practice Address - City:FT. STEWART
Practice Address - State:GA
Practice Address - Zip Code:31314-5611
Practice Address - Country:US
Practice Address - Phone:912-435-5696
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2010-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1215152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152W00000XEye and Vision Services ProvidersOptometrist