Provider Demographics
NPI:1609072933
Name:WAHL, MELANIE JANETTE (MD)
Entity Type:Individual
Prefix:DR
First Name:MELANIE
Middle Name:JANETTE
Last Name:WAHL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MELANIE
Other - Middle Name:JANETTE
Other - Last Name:BALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 955534
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63195-5534
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1011 BOWLES AVE STE 300
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MO
Practice Address - Zip Code:63026
Practice Address - Country:US
Practice Address - Phone:636-496-5030
Practice Address - Fax:636-496-5035
Is Sole Proprietor?:No
Enumeration Date:2007-06-24
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009019545207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP00878235OtherRAILROAD MEDICARE
MOP00878235OtherRAILROAD MEDICARE
MOP00878235OtherRAILROAD MEDICARE
MO1609072933Medicaid