Provider Demographics
NPI:1104823335
Name:WAHLSTROM, JOHN GEOFFREY (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:GEOFFREY
Last Name:WAHLSTROM
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 1:565 SNELLING AVE S
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55116-1525
Mailing Address - Country:US
Mailing Address - Phone:651-698-0386
Mailing Address - Fax:651-698-0483
Practice Address - Street 1:565 SNELLING AVE S
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55116-1525
Practice Address - Country:US
Practice Address - Phone:651-698-0386
Practice Address - Fax:651-698-0483
Is Sole Proprietor?:No
Enumeration Date:2005-07-01
Last Update Date:2013-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN28022207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN564077600Medicare ID - Type Unspecified
MND28714Medicare UPIN
MN030000059Medicare ID - Type Unspecified