Provider Demographics
NPI:1083731525
Name:WOLF, JEFFREY STEPHEN (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:STEPHEN
Last Name:WOLF
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 1:3235 ACADEMY AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23703-3200
Mailing Address - Country:US
Mailing Address - Phone:757-484-9653
Mailing Address - Fax:757-484-9662
Practice Address - Street 1:3235 ACADEMY AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23703-3200
Practice Address - Country:US
Practice Address - Phone:757-484-9653
Practice Address - Fax:757-484-9662
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2008-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101031444208C00000X
NC9400174208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA292832OtherMAMSI
VA072337OtherANTHEM
VA200136OtherOPTIMA
NC890528EMedicaid
VA005841232Medicaid
VA00V712C97Medicare ID - Type Unspecified
VA280000251Medicare ID - Type UnspecifiedMEDICARE RAILROAD
VA072337OtherANTHEM
VA292832OtherMAMSI