Provider Demographics
NPI:1245230903
Name:WAHL, GARY J (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:J
Last Name:WAHL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 23229
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42304-3229
Mailing Address - Country:US
Mailing Address - Phone:270-686-8500
Mailing Address - Fax:270-685-5467
Practice Address - Street 1:1325 TRIPLETT ST
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-3163
Practice Address - Country:US
Practice Address - Phone:270-686-8500
Practice Address - Fax:270-685-5467
Is Sole Proprietor?:No
Enumeration Date:2005-07-26
Last Update Date:2019-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY23029207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000550297OtherCHS INC ANTHEM PIN #
KY6423029500Medicaid
KY0268502Medicare PIN
C69394Medicare UPIN
KYK185760Medicare PIN
KY3397744Medicare PIN