Provider Demographics
NPI:1124237508
Name:WALSH, TIMOTHY RILEY (DOM)
Entity type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:RILEY
Last Name:WALSH
Suffix:
Gender:M
Credentials:DOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 PINON AVE
Mailing Address - Street 2:
Mailing Address - City:CEDAR CREST
Mailing Address - State:NM
Mailing Address - Zip Code:87008-9715
Mailing Address - Country:US
Mailing Address - Phone:847-802-2245
Mailing Address - Fax:
Practice Address - Street 1:605 EDWARDS AVE
Practice Address - Street 2:
Practice Address - City:WEST DUNDEE
Practice Address - State:IL
Practice Address - Zip Code:60118-2741
Practice Address - Country:US
Practice Address - Phone:847-802-2245
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2022-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDOM1266171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist