Basic Information
| Provider Information | |||||||||
| NPI: | 1588613749 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WOLFF | ||||||||
| FirstName: | LARRY | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 5301 F ST | ||||||||
| Address2: | SUITE 111 | ||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958193226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9164513400 | ||||||||
| FaxNumber: | 9164521733 | ||||||||
| Practice Location | |||||||||
| Address1: | 5301 F ST | ||||||||
| Address2: | SUITE 111 | ||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958193226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9164513400 | ||||||||
| FaxNumber: | 9164521733 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2006 | ||||||||
| LastUpdateDate: | 09/24/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | G34846 | CA | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 00G348460 | 05 | CA | MEDICAID | 1609041649 | 01 | CA | GROUP MEDICARE PIN 1609041649 | OTHER |