Provider Demographics
NPI:1790730497
Name:MAHAR, WALLY SHERMAN (MD)
Entity Type:Individual
Prefix:
First Name:WALLY
Middle Name:SHERMAN
Last Name:MAHAR
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 1:21 MIDLAND ST
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48203-3727
Mailing Address - Country:US
Mailing Address - Phone:586-556-1997
Mailing Address - Fax:313-731-7025
Practice Address - Street 1:21 MIDLAND ST
Practice Address - Street 2:
Practice Address - City:HIGHLAND PARK
Practice Address - State:MI
Practice Address - Zip Code:48203-3727
Practice Address - Country:US
Practice Address - Phone:248-698-2094
Practice Address - Fax:877-218-9387
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-23
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301030215208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
E82642Medicare UPIN
E06455014Medicare ID - Type Unspecified