Healthcare Provider Details

I. General information

NPI: 1710253893
Provider Name (Legal Business Name): MICHAEL WAHL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2012
Last Update Date: 02/19/2021
Certification Date: 02/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 NE NEFF RD
BEND OR
97701-6015
US

IV. Provider business mailing address

501 NW ELKS DR
CORVALLIS OR
97330-3757
US

V. Phone/Fax

Practice location:
  • Phone: 541-706-5800
  • Fax:
Mailing address:
  • Phone: 415-353-7175
  • Fax: 415-353-9883

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License NumberMD183583
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: