Provider Demographics
NPI:1306888730
Name:WALSTON, JEREMY (MD)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:WALSTON
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:PO BOX 64264
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-4264
Mailing Address - Country:US
Mailing Address - Phone:410-550-0925
Mailing Address - Fax:
Practice Address - Street 1:5505 HOPKINS BAYVIEW CIR
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21224-6821
Practice Address - Country:US
Practice Address - Phone:410-550-0925
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-11
Last Update Date:2025-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD38849207R00000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD548201100Medicaid
MD144ME636Medicare PIN
MDE17137Medicare UPIN