Provider Demographics
NPI:1154315125
Name:WOLF, KAREN SUE (OD)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:SUE
Last Name:WOLF
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 PROFESSIONAL DR
Mailing Address - Street 2:STE 300
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32082-6216
Mailing Address - Country:US
Mailing Address - Phone:904-285-8448
Mailing Address - Fax:904-285-3410
Practice Address - Street 1:150 PROFESSIONAL DR
Practice Address - Street 2:STE 300
Practice Address - City:PONTE VEDRA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32082-6216
Practice Address - Country:US
Practice Address - Phone:904-285-8448
Practice Address - Fax:904-285-3410
Is Sole Proprietor?:No
Enumeration Date:2005-09-07
Last Update Date:2008-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC2406152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U31918Medicare UPIN
FL19789ZMedicare ID - Type Unspecified
FL0664110001Medicare NSC