Provider Demographics
NPI:1285661728
Name:WAHL, SALLIE MITCHELL (OD PC)
Entity Type:Individual
Prefix:MRS
First Name:SALLIE
Middle Name:MITCHELL
Last Name:WAHL
Suffix:
Gender:F
Credentials:OD PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 N SPENCE AVE
Mailing Address - Street 2:
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27534
Mailing Address - Country:US
Mailing Address - Phone:919-778-7110
Mailing Address - Fax:919-778-6057
Practice Address - Street 1:515 N SPENCE AVE
Practice Address - Street 2:
Practice Address - City:GOLDSBORO
Practice Address - State:NC
Practice Address - Zip Code:27534
Practice Address - Country:US
Practice Address - Phone:919-778-7110
Practice Address - Fax:919-778-6057
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2011-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1961152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCDA3706OtherMEDICARE RAILROAD
NC899024CMedicaid
NC9024COtherBCBSNC
NCDA3706OtherMEDICARE RAILROAD
NC899024CMedicaid
NC9024COtherBCBSNC