Provider Demographics
NPI:1114289311
Name:WOLF, SUSAN CAROL
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:CAROL
Last Name:WOLF
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10128-1202
Mailing Address - Country:US
Mailing Address - Phone:212-249-3314
Mailing Address - Fax:212-734-3838
Practice Address - Street 1:1100 PARK AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10128-1202
Practice Address - Country:US
Practice Address - Phone:212-249-3314
Practice Address - Fax:212-734-3838
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-13
Last Update Date:2012-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY191007207VG0400X, 207ZP0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
No207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology