Basic Information
Provider Information | |||||||||
NPI: | 1114918273 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WOLF EYE ASSOCIATES PA | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 249 MAIN ST | ||||||||
Address2: |   | ||||||||
City: | LEWISTON | ||||||||
State: | ME | ||||||||
PostalCode: | 042407053 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2077839653 | ||||||||
FaxNumber: | 2077864362 | ||||||||
Practice Location | |||||||||
Address1: | 249 MAIN ST | ||||||||
Address2: |   | ||||||||
City: | LEWISTON | ||||||||
State: | ME | ||||||||
PostalCode: | 042407053 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2077839653 | ||||||||
FaxNumber: | 2077864362 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/28/2005 | ||||||||
LastUpdateDate: | 08/03/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WOLF | ||||||||
AuthorizedOfficialFirstName: | KENNETH | ||||||||
AuthorizedOfficialMiddleName: | P | ||||||||
AuthorizedOfficialTitleorPosition: | OPHTHALMOLOGIST/OWNER | ||||||||
AuthorizedOfficialTelephone: | 2077839653 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |   |
ID Information
ID | Type | State | Issuer | Description | 112040000 | 05 | ME |   | MEDICAID | 30008301 | 01 | NH | NH MEDICAID | OTHER | C13306 | 01 | ME | RR MEDICARE | OTHER |