Provider Demographics
NPI:1003983644
Name:WOLF, GERALD LEON (FNAO)
Entity Type:Individual
Prefix:MR
First Name:GERALD
Middle Name:LEON
Last Name:WOLF
Suffix:
Gender:M
Credentials:FNAO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1302 N HIGHWAY 99 W
Mailing Address - Street 2:
Mailing Address - City:MCMINNVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97128-9999
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1302 N HIGHWAY 99 W
Practice Address - Street 2:
Practice Address - City:MCMINNVILLE
Practice Address - State:OR
Practice Address - Zip Code:97128-9999
Practice Address - Country:US
Practice Address - Phone:503-472-5665
Practice Address - Fax:503-474-1585
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR0725920001Medicare NSC