Provider Demographics
NPI:1689609646
Name:WAHL, WALTER (MD)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:
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 1:3800 S W S YOUNG DR STE 407
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76542-3374
Mailing Address - Country:US
Mailing Address - Phone:254-252-3748
Mailing Address - Fax:254-549-0086
Practice Address - Street 1:3800 S W S YOUNG DR STE 407
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76542-3374
Practice Address - Country:US
Practice Address - Phone:254-252-3748
Practice Address - Fax:254-549-0086
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2019-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY149920-1207Q00000X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00816344Medicaid