Provider Demographics
NPI:1053478479
Name:WAHL, ANDREW VERNON (DPM)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:VERNON
Last Name:WAHL
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1960 ESSINGTON RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435-1617
Mailing Address - Country:US
Mailing Address - Phone:815-436-3555
Mailing Address - Fax:
Practice Address - Street 1:1960 ESSINGTON RD
Practice Address - Street 2:SUITE 103
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-1617
Practice Address - Country:US
Practice Address - Phone:815-436-3555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2009-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016-004460213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL5536200001Medicare NSC
IL942970Medicare PIN
ILU12226Medicare UPIN