Provider Demographics
NPI:1093752776
Name:WOLFE, MICHAEL BENJAMIN (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:BENJAMIN
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 1:2100 POWELL STREET
Mailing Address - Street 2:STE 920
Mailing Address - City:EMERYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94608-1803
Mailing Address - Country:US
Mailing Address - Phone:510-350-2777
Mailing Address - Fax:
Practice Address - Street 1:815 POLLARD ROAD
Practice Address - Street 2:
Practice Address - City:LOS GATOS
Practice Address - State:CA
Practice Address - Zip Code:95032-1400
Practice Address - Country:US
Practice Address - Phone:408-378-6131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA63089207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH00902Medicare UPIN