Basic Information
| Provider Information | |||||||||
| NPI: | 1306821228 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WOLF | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5530 BIRDCAGE STREET | ||||||||
| Address2: | SUITE 145 | ||||||||
| City: | CITRUS HEIGHTS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2099567725 | ||||||||
| FaxNumber: | 2099567733 | ||||||||
| Practice Location | |||||||||
| Address1: | 6501 COYLE AVE | ||||||||
| Address2: | |||||||||
| City: | CARMICHAEL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9165375000 | ||||||||
| FaxNumber: | 9168512884 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2005 | ||||||||
| LastUpdateDate: | 12/17/2010 | ||||||||
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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 | 207L00000X | A837800 | CA | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | G63319 | CA | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 00G633190 | 05 | CA | MEDICAID |