Provider Demographics
NPI:1215943683
Name:WAHLE, GREGORY R (MD)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:R
Last Name:WAHLE
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 1:679 E COUNTY LINE RD
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46143-1049
Mailing Address - Country:US
Mailing Address - Phone:317-807-1262
Mailing Address - Fax:317-859-4268
Practice Address - Street 1:12188A N MERIDIAN ST
Practice Address - Street 2:SUITE # 200
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-4578
Practice Address - Country:US
Practice Address - Phone:317-564-5100
Practice Address - Fax:317-564-5556
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01040415A208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200288740OtherMEDICAID GROUP NUMBER
IN1487680518OtherGROUP NPI
IN100319050Medicaid
IN340019239OtherMEDICARE RAILROAD
IN000000198907OtherANTHEM PIN NUMBER
IN100194370OtherMEDICAID GROUP NUMBER
IN000000198907OtherANTHEM PIN NUMBER
IN1487680518OtherGROUP NPI
IN100194370OtherMEDICAID GROUP NUMBER
IN345000VMedicare PIN
INF38827Medicare UPIN