Basic Information
| Provider Information | |||||||||
| NPI: | 1578552766 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WOLFSON | ||||||||
| FirstName: | JOSEPH | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9 HEALTHCARE DR | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | BIDDEFORD | ||||||||
| State: | ME | ||||||||
| PostalCode: | 040059449 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2072829080 | ||||||||
| FaxNumber: | 2072829180 | ||||||||
| Practice Location | |||||||||
| Address1: | 4 SHAPE DR | ||||||||
| Address2: | |||||||||
| City: | KENNEBUNK | ||||||||
| State: | ME | ||||||||
| PostalCode: | 040436745 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2074678988 | ||||||||
| FaxNumber: | 2074678969 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2005 | ||||||||
| LastUpdateDate: | 02/09/2011 | ||||||||
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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 | 49653 | MA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 018043 | ME | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 433587799 | 05 | ME | MEDICAID | G01060 | 01 | MA | BLUE CROSS BLUE SHIELD-MA | OTHER | 0166952 | 05 | MA | MEDICAID |