Basic Information
| Provider Information | |||||||||
| NPI: | 1588649693 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WOLF | ||||||||
| FirstName: | DOUGLAS | ||||||||
| MiddleName: | C. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5671 PEACHTREE DUNWOODY RD STE 600 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303425020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4042579000 | ||||||||
| FaxNumber: | 4048479792 | ||||||||
| Practice Location | |||||||||
| Address1: | 5671 PEACHTREE DUNWOODY RD NE | ||||||||
| Address2: | SUITE 600 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303425000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4042579000 | ||||||||
| FaxNumber: | 4048479792 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2005 | ||||||||
| LastUpdateDate: | 02/05/2018 | ||||||||
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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 | 207RG0100X | 27135 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 00309823C | 05 | GA | MEDICAID |