Healthcare Provider Details

I. General information

NPI: 1205572302
Provider Name (Legal Business Name): JOSHUA SCOTT WAHLSTROM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2022
Last Update Date: 12/29/2025
Certification Date: 12/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308 CEDAR ST
DECATUR MI
49045-8854
US

IV. Provider business mailing address

308 CEDAR ST
DECATUR MI
49045-8854
US

V. Phone/Fax

Practice location:
  • Phone: 269-470-1620
  • Fax:
Mailing address:
  • Phone: 269-470-1620
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number01097796A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number4351049581
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: