Healthcare Provider Details

I. General information

NPI: 1750399275
Provider Name (Legal Business Name): MELVIN M WAHL JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: MELVIN M WAHL JR. MD

II. Dates (important events)

Enumeration Date: 08/03/2006
Last Update Date: 10/03/2024
Certification Date: 10/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 GOETHALS DR STE B
RICHLAND WA
99352-3301
US

IV. Provider business mailing address

550 GAGE BLVD STE 101
RICHLAND WA
99352-9532
US

V. Phone/Fax

Practice location:
  • Phone: 509-942-3080
  • Fax: 509-942-3085
Mailing address:
  • Phone: 509-473-0637
  • Fax: 509-627-2983

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License NumberA95817
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License NumberMD00047477
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: