Provider Demographics
NPI:1821155755
Name:WAHL, JONATHAN (MD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
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 1:471 N BROADWAY
Mailing Address - Street 2:SUITE 278
Mailing Address - City:JERICHO
Mailing Address - State:NY
Mailing Address - Zip Code:11753-2106
Mailing Address - Country:US
Mailing Address - Phone:516-695-6340
Mailing Address - Fax:718-368-0400
Practice Address - Street 1:471 N BROADWAY
Practice Address - Street 2:SUITE 278
Practice Address - City:JERICHO
Practice Address - State:NY
Practice Address - Zip Code:11753-2106
Practice Address - Country:US
Practice Address - Phone:516-695-6340
Practice Address - Fax:718-368-0400
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2009-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY232419208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02848373Medicaid
NY4825XCK011Medicare PIN
NY02848373Medicaid
NYI74217Medicare UPIN
NYA400008015Medicare PIN