Provider Demographics
NPI:1285686436
Name:WAHLSTROM, NORMAN O JR (MD)
Entity Type:Individual
Prefix:
First Name:NORMAN
Middle Name:O
Last Name:WAHLSTROM
Suffix:JR
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:PO BOX 727
Mailing Address - Street 2:
Mailing Address - City:BRIGHAM CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84302-0727
Mailing Address - Country:US
Mailing Address - Phone:435-734-0101
Mailing Address - Fax:435-734-0103
Practice Address - Street 1:5475 SOUTH 500 EAST
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84405
Practice Address - Country:US
Practice Address - Phone:801-479-2392
Practice Address - Fax:801-479-2396
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1669681205207ZP0102X, 207ZP0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Not Answered207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
D26550Medicare UPIN