Provider Demographics
NPI:1023044773
Name:WOLFSON, ERIC M (DO)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:M
Last Name:WOLFSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10788 RIVENDELL AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89135-1803
Mailing Address - Country:US
Mailing Address - Phone:702-566-5343
Mailing Address - Fax:702-566-4549
Practice Address - Street 1:6803 W TROPICANA AVE
Practice Address - Street 2:STE #100
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89103-4926
Practice Address - Country:US
Practice Address - Phone:702-452-2525
Practice Address - Fax:702-452-2534
Is Sole Proprietor?:No
Enumeration Date:2006-06-24
Last Update Date:2007-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV036103109207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002018654Medicaid
NVV100826Medicare PIN
NVV100826Medicare ID - Type UnspecifiedINDIVIDUAL PROVIDER NO.