Provider Demographics
NPI:1003594375
Name:WAHLQUIST, HYRUM (OD)
Entity Type:Individual
Prefix:
First Name:HYRUM
Middle Name:
Last Name:WAHLQUIST
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2800 ROSS CLARK CIR
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36301-2040
Mailing Address - Country:US
Mailing Address - Phone:334-793-2211
Mailing Address - Fax:
Practice Address - Street 1:4340 LAFAYETTE ST
Practice Address - Street 2:
Practice Address - City:MARIANNA
Practice Address - State:FL
Practice Address - Zip Code:32446-2916
Practice Address - Country:US
Practice Address - Phone:850-482-2336
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-07
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC6285152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist