Provider Demographics
NPI:1356328181
Name:WAHLSTROM, RICHARD (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
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 1:2500 SHERIDAN AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55405-2342
Mailing Address - Country:US
Mailing Address - Phone:612-377-7863
Mailing Address - Fax:612-374-1355
Practice Address - Street 1:2500 SHERIDAN AVE S
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55405-2342
Practice Address - Country:US
Practice Address - Phone:612-377-7863
Practice Address - Fax:612-374-1355
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-22
Last Update Date:2009-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN21093207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine