Basic Information
| Provider Information | |||||||||
| NPI: | 1467802595 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WOLFE | ||||||||
| FirstName: | JESSE | ||||||||
| MiddleName: | RICHARD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | III | ||||||||
| Credential: | DPM | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1200 1ST AVE E STE C | ||||||||
| Address2: | |||||||||
| City: | SPENCER | ||||||||
| State: | IA | ||||||||
| PostalCode: | 513014342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7122627511 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1200 1ST AVE E STE C | ||||||||
| Address2: | |||||||||
| City: | SPENCER | ||||||||
| State: | IA | ||||||||
| PostalCode: | 513014342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7122627511 | ||||||||
| FaxNumber: | 7122623658 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2016 | ||||||||
| LastUpdateDate: | 07/10/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 213ES0103X | 097365 | IA | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
No ID Information.