Provider Demographics
NPI:1073629739
Name:WOLFE, WALTER RAY (MD)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:RAY
Last Name:WOLFE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:163 RIVER OAKS DR STE 204
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MS
Mailing Address - Zip Code:39046-5324
Mailing Address - Country:US
Mailing Address - Phone:601-855-4881
Mailing Address - Fax:601-859-5454
Practice Address - Street 1:163 RIVER OAKS DR STE 204
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MS
Practice Address - Zip Code:39046
Practice Address - Country:US
Practice Address - Phone:601-855-4881
Practice Address - Fax:601-859-5454
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2018-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS11096174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00010644Medicaid
MS00010644Medicaid