Basic Information
| Provider Information | |||||||||
| NPI: | 1174608319 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WOLF | ||||||||
| FirstName: | MITCHELL | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 258884 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731258884 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052313857 | ||||||||
| FaxNumber: | 4052727977 | ||||||||
| Practice Location | |||||||||
| Address1: | 3214 KETHLEY RD | ||||||||
| Address2: | |||||||||
| City: | SHAWNEE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 748049625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052735801 | ||||||||
| FaxNumber: | 4058783794 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2006 | ||||||||
| LastUpdateDate: | 11/11/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 10580 | NV | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 18589 | OK | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | P00366183 | 01 | NV | RAILROAD MEDICARE | OTHER | 100506264 | 05 | NV | MEDICAID |