Provider Demographics
NPI:1114991056
Name:WAHL, LARRY HOWARD (DO)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:HOWARD
Last Name:WAHL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:575 ROBBINS RD STE D
Mailing Address - Street 2:
Mailing Address - City:GRAND HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49417-2695
Mailing Address - Country:US
Mailing Address - Phone:616-847-0003
Mailing Address - Fax:616-847-8912
Practice Address - Street 1:575 ROBBINS RD STE D
Practice Address - Street 2:
Practice Address - City:GRAND HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49417-2695
Practice Address - Country:US
Practice Address - Phone:616-847-0003
Practice Address - Fax:616-847-8912
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-16
Last Update Date:2017-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI51010098862084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
F52691Medicare UPIN