1649357492 NPI number — DR. JOSEPH I WOLFSDORF MB, BCH

Table of content: DR. JOSEPH I WOLFSDORF MB, BCH (NPI 1649357492)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649357492 NPI number — DR. JOSEPH I WOLFSDORF MB, BCH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WOLFSDORF
Provider First Name:
JOSEPH
Provider Middle Name:
I
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MB, BCH
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:
1649357492
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
300 LONGWOOD AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOSTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02115-5724
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-355-7476
Provider Business Mailing Address Fax Number:
617-730-0194

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
333 LONGWOOD AVE
Provider Second Line Business Practice Location Address:
FLOOR 6
Provider Business Practice Location Address City Name:
BOSTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02115-5711
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-355-7477
Provider Business Practice Location Address Fax Number:
617-730-0194
Provider Enumeration Date:
11/01/2006

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: 208000000X , with the licence number:  40744 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2080P0205X , with the licence number: 40744 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2082180 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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