Provider Demographics
NPI:1134163124
Name:WAHL, BRENDA J (OD)
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:J
Last Name:WAHL
Suffix:
Gender:F
Credentials:OD
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Mailing Address - Street 1:8103 CLEARVISTA PKWY
Mailing Address - Street 2:SUITE 240
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46256-5628
Mailing Address - Country:US
Mailing Address - Phone:317-845-9488
Mailing Address - Fax:317-570-7433
Practice Address - Street 1:8103 CLEARVISTA PKWY
Practice Address - Street 2:SUITE 240
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46256-5628
Practice Address - Country:US
Practice Address - Phone:317-845-9488
Practice Address - Fax:317-570-7433
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN18003015A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
INU76305Medicare UPIN
IN673220CMedicare ID - Type Unspecified