Provider Demographics
NPI:1073543583
Name:WAHLERT, CHARLES HANCOCK (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:HANCOCK
Last Name:WAHLERT
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 1:803 THOMAS ST
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76201-2496
Mailing Address - Country:US
Mailing Address - Phone:940-383-1895
Mailing Address - Fax:
Practice Address - Street 1:521 BRYAN ST
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76201-2705
Practice Address - Country:US
Practice Address - Phone:940-380-1985
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE6190207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXB27393Medicare UPIN
TX81H577Medicare ID - Type Unspecified