Basic Information
| Provider Information | |||||||||
| NPI: | 1518929058 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WOLF | ||||||||
| FirstName: | LAWRENCE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 31204 | ||||||||
| Address2: | |||||||||
| City: | HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2122563682 | ||||||||
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| Practice Location | |||||||||
| Address1: | 349 HENRY STREET | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7187801473 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 215667 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 02061705 | 05 | NY | MEDICAID |