Provider Demographics
NPI:1407481229
Name:WALSH, KEIFER PATRICK (DO)
Entity type:Individual
Prefix:
First Name:KEIFER
Middle Name:PATRICK
Last Name:WALSH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24008 BELLEAU AVE
Mailing Address - Street 2:
Mailing Address - City:STAFFORD
Mailing Address - State:VA
Mailing Address - Zip Code:22556
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:24008 BELLEAU AVE
Practice Address - Street 2:
Practice Address - City:STAFFORD
Practice Address - State:VA
Practice Address - Zip Code:22556
Practice Address - Country:US
Practice Address - Phone:703-432-6389
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-12
Last Update Date:2024-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171000000X
VA0102208533207Q00000X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No171000000XOther Service ProvidersMilitary Health Care Provider
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty