Basic Information
| Provider Information | |||||||||
| NPI: | 1467615070 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WAHL | ||||||||
| FirstName: | CARTER | ||||||||
| MiddleName: | ELLIOTT | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 FIR ST | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921012327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6194461646 | ||||||||
| FaxNumber: | 8586362032 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 FIR ST | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921012327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6194461646 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2008 | ||||||||
| LastUpdateDate: | 07/31/2017 | ||||||||
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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 | 207ND0900X | A85194 | CA | N | Allopathic & Osteopathic Physicians | Dermatology | Dermatopathology | 207ZP0102X | A85194 | CA | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | A85194 | 05 | CA | MEDICAID |