Provider Demographics
NPI:1982651154
Name:WAHLBERG, NEIL E (MD)
Entity Type:Individual
Prefix:
First Name:NEIL
Middle Name:E
Last Name:WAHLBERG
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 1:2015 E NEWPORT AVE
Mailing Address - Street 2:SUITE 118
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53211-2984
Mailing Address - Country:US
Mailing Address - Phone:414-961-8886
Mailing Address - Fax:414-964-1223
Practice Address - Street 1:2015 E NEWPORT AVE
Practice Address - Street 2:SUITE 118
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53211-2984
Practice Address - Country:US
Practice Address - Phone:414-961-8886
Practice Address - Fax:414-964-1223
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2007-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI23290207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30307300Medicaid
WI30307300Medicaid