Provider Demographics
NPI:1063417087
Name:WAHL, JEFFRY ROSS (MD)
Entity type:Individual
Prefix:
First Name:JEFFRY
Middle Name:ROSS
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 1:835 EDMOND STREET
Mailing Address - Street 2:
Mailing Address - City:HARMONY
Mailing Address - State:PA
Mailing Address - Zip Code:16037
Mailing Address - Country:US
Mailing Address - Phone:724-368-8081
Mailing Address - Fax:
Practice Address - Street 1:835 EDMUND ST
Practice Address - Street 2:
Practice Address - City:HARMONY
Practice Address - State:PA
Practice Address - Zip Code:16037-9109
Practice Address - Country:US
Practice Address - Phone:724-452-8186
Practice Address - Fax:724-452-8599
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2010-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD040649L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAE63831Medicare UPIN
PA96248Medicare ID - Type Unspecified