Basic Information
| Provider Information | |||||||||
| NPI: | 1376827642 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WOLANIN | ||||||||
| FirstName: | ALFRED | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | III | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | BUMED, CENTRALIZED CREDENTIAL & PRIVILEGING DIRECTORATE | ||||||||
| Address2: | 554 KEILY STREET | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32212 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | BUMED, CENTRALIZED CREDENTIAL & PRIVILEGING DIRECTORATE | ||||||||
| Address2: | 554 KEILY STREET | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7579537550 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2011 | ||||||||
| LastUpdateDate: | 07/01/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 1 | PA | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207W00000X | 0101253385 | VA | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
No ID Information.