Provider Demographics
NPI:1124482898
Name:WAHLBERG, ELIZABETH ANNE (MD)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ANNE
Last Name:WAHLBERG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:ANNE
Other - Last Name:STROEHER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1924 N 46TH ST
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98103-6810
Mailing Address - Country:US
Mailing Address - Phone:406-560-3085
Mailing Address - Fax:
Practice Address - Street 1:111 COLCHESTER AVE # 222WP2
Practice Address - Street 2:UVM MEDICAL CENTER, DEPT OF INTERNAL MEDICINE
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-1473
Practice Address - Country:US
Practice Address - Phone:802-847-2700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-08
Last Update Date:2017-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VT060.0004558207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program