Basic Information
| Provider Information | |||||||||
| NPI: | 1942567243 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WOLFORD | ||||||||
| FirstName: | BRENT | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4200 UNIVERSITY AVENUE | ||||||||
| Address2: | STE 104 | ||||||||
| City: | CLIVE | ||||||||
| State: | IA | ||||||||
| PostalCode: | 50266 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5159610453 | ||||||||
| FaxNumber: | 5159612714 | ||||||||
| Practice Location | |||||||||
| Address1: | 12368 STRATFORD DR STE 300 | ||||||||
| Address2: | |||||||||
| City: | CLIVE | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503258149 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152268408 | ||||||||
| FaxNumber: | 5152268408 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2012 | ||||||||
| LastUpdateDate: | 06/06/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | CDR.0001325 | CO | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | MD-44322 | IA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.