Provider Demographics
NPI:1043251150
Name:WOLF, MICHAEL L (OD)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:L
Last Name:WOLF
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 CLIFF CAVE ROAD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63129
Mailing Address - Country:US
Mailing Address - Phone:314-846-8232
Mailing Address - Fax:314-293-9345
Practice Address - Street 1:111 CLIFF CAVE ROAD
Practice Address - Street 2:SUITE 100
Practice Address - City:ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63129
Practice Address - Country:US
Practice Address - Phone:314-846-8232
Practice Address - Fax:314-293-9345
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2010-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT02717152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO537942807Medicaid
MO003007267Medicare ID - Type Unspecified
MO537942807Medicaid