Basic Information
| Provider Information | |||||||||
| NPI: | 1134293061 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WAHL | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | ALAN | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2701 E ELVIRA RD | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857567124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5206260923 | ||||||||
| FaxNumber: | 5206262808 | ||||||||
| Practice Location | |||||||||
| Address1: | 535 N WILMOT RD | ||||||||
| Address2: | SUITE #101 | ||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5206949988 | ||||||||
| FaxNumber: | 5206949917 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2006 | ||||||||
| LastUpdateDate: | 05/22/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 15421 | AZ | Y | Allopathic & Osteopathic Physicians | Pediatrics | 2080A0000X | 15421 | AZ | N | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine |
ID Information
| ID | Type | State | Issuer | Description | 268450 | 05 | AZ | MEDICAID |