Provider Demographics
NPI:1467400317
Name:WAHLBERG, JOSEPH C (MD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:C
Last Name:WAHLBERG
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 1:2829 UNIVERSITY AVE SE STE 730
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55414-3279
Mailing Address - Country:US
Mailing Address - Phone:612-439-1867
Mailing Address - Fax:
Practice Address - Street 1:333 SMITH AVE N
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-2344
Practice Address - Country:US
Practice Address - Phone:651-241-5398
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2022-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI55716-020207P00000X
MN48329207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNI51727Medicare UPIN