Provider Demographics
NPI:1407884737
Name:WAHL, WILLIAM BRENT (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:BRENT
Last Name:WAHL
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 1:1819 DENVER WEST DRIVE
Mailing Address - Street 2:STE. 101
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80401
Mailing Address - Country:US
Mailing Address - Phone:303-223-4457
Mailing Address - Fax:303-964-1438
Practice Address - Street 1:11600 WEST 2ND PLACE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80228
Practice Address - Country:US
Practice Address - Phone:720-321-0000
Practice Address - Fax:720-321-1621
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2016-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO32653174400000X
CODR.00326532085R0202X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No174400000XOther Service ProvidersSpecialist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01326537Medicaid
CO300049148OtherRAILROAD MEDICARE
COCF2068Medicare PIN
CO351442YLB8Medicare PIN
CO300049148OtherRAILROAD MEDICARE
COC461118Medicare PIN