1467458000 NPI number — JACK M WOLFSON D.O.

Table of content: JACK M WOLFSON D.O. (NPI 1467458000)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467458000 NPI number — JACK M WOLFSON D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WOLFSON
Provider First Name:
JACK
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1467458000
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/27/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10585 N TATUM BLVD
Provider Second Line Business Mailing Address:
STE D135
Provider Business Mailing Address City Name:
PARADISE VALLEY
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85253-1073
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-535-6844
Provider Business Mailing Address Fax Number:
480-535-6845

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10585 N TATUM BLVD
Provider Second Line Business Practice Location Address:
STE D135
Provider Business Practice Location Address City Name:
PARADISE VALLEY
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85253-1073
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-535-6844
Provider Business Practice Location Address Fax Number:
480-535-6845
Provider Enumeration Date:
06/27/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X , with the licence number:  3761 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1Z6403 . This is a "HEALTHNET" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 060068481 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 25-01062 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 690257 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: AZ0714780 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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