Provider Demographics
NPI:1528142205
Name:WALSH, ERIC WYATT (MD)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:WYATT
Last Name:WALSH
Suffix:
Gender:M
Credentials:MD
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3181 SW SAM JACKSON PARK RD.
Mailing Address - Street 2:OREGON HEALTH SCIENCES UNIVERSITY
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239
Mailing Address - Country:US
Mailing Address - Phone:503-418-3900
Mailing Address - Fax:503-418-8293
Practice Address - Street 1:3181 SW SAM JACKSON PARK RD.
Practice Address - Street 2:OREGON HEALTH AND SCIENCE UNIVERSITY
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-3098
Practice Address - Country:US
Practice Address - Phone:503-494-6616
Practice Address - Fax:503-494-4691
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2009-08-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OR17309207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR17309OtherLICENSE
NY00903700Medicaid