Healthcare Provider Details

I. General information

NPI: 1417039801
Provider Name (Legal Business Name): MARC WAHLQUIST M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 04/29/2026
Certification Date: 04/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6340 SUGARLOAF PKWY STE 350
DULUTH GA
30097-4348
US

IV. Provider business mailing address

275 INTERSTATE NORTH CIR SE STE 500
ATLANTA GA
30339-2565
US

V. Phone/Fax

Practice location:
  • Phone: 404-282-1484
  • Fax: 404-282-0946
Mailing address:
  • Phone: 770-953-6929
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number35084068
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number110622
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: