Provider Demographics
NPI:1154743987
Name:WAHL, KEITH JAY (MD)
Entity type:Individual
Prefix:DR
First Name:KEITH
Middle Name:JAY
Last Name:WAHL
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:8735 NOTTINGHAM PL
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-2129
Mailing Address - Country:US
Mailing Address - Phone:858-518-2190
Mailing Address - Fax:858-455-0655
Practice Address - Street 1:8735 NOTTINGHAM PL
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-2129
Practice Address - Country:US
Practice Address - Phone:858-518-2190
Practice Address - Fax:858-455-0655
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-14
Last Update Date:2019-04-30
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAA24790207YS0123X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic Surgery