Provider Demographics
NPI:1609854611
Name:WALCOTT, SEAN S (MD)
Entity type:Individual
Prefix:DR
First Name:SEAN
Middle Name:S
Last Name:WALCOTT
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 638257
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-8257
Mailing Address - Country:US
Mailing Address - Phone:888-952-6772
Mailing Address - Fax:856-694-5179
Practice Address - Street 1:33155 ANNAPOLIS ST
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:MI
Practice Address - Zip Code:48184-2405
Practice Address - Country:US
Practice Address - Phone:734-467-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2025-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301078051207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI10-4631349Medicaid
MI10-4631376Medicaid
MI11311888OtherCAQH
MI10-4631358Medicaid
MI10-4631385Medicaid
MI10-4710344Medicaid
MI10-4710335Medicaid
MI10-4631394Medicaid
MI10-4710353Medicaid