Basic Information
| Provider Information | |||||||||
| NPI: | 1598923336 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WOLFE | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | D. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1510 WHITROCK AVE | ||||||||
| Address2: | |||||||||
| City: | WISCONSIN RAPIDS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 544944207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7157120241 | ||||||||
| FaxNumber: | 7157120004 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 MARTHA JEFFERSON DR | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTESVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 229114668 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4346547000 | ||||||||
| FaxNumber: | 4346548339 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/29/2008 | ||||||||
| LastUpdateDate: | 06/10/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 0101271662 | VA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 30207819 | 05 | NH | MEDICAID | 1015058 | 05 | VT | MEDICAID | 14004 | 01 | NH | LICENSE | OTHER |