Provider Demographics
NPI:1801813688
Name:WAHLSTROM, HAKAN ERIK (MD)
Entity Type:Individual
Prefix:DR
First Name:HAKAN
Middle Name:ERIK
Last Name:WAHLSTROM
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 1:4500 BROCKTON AVE.
Mailing Address - Street 2:SUITE 306
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92501-4027
Mailing Address - Country:US
Mailing Address - Phone:951-275-9000
Mailing Address - Fax:951-275-5262
Practice Address - Street 1:4500 BROCKTON AVE.
Practice Address - Street 2:SUITE 306
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92501-4027
Practice Address - Country:US
Practice Address - Phone:951-275-9000
Practice Address - Fax:951-275-5262
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-16
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA37140208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A371400Medicaid
CA00A371400Medicaid