Provider Demographics
NPI:1164765947
Name:WOLF, VIRA (MD)
Entity Type:Individual
Prefix:
First Name:VIRA
Middle Name:
Last Name:WOLF
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:479 HARTFORD DR
Mailing Address - Street 2:
Mailing Address - City:NUTLEY
Mailing Address - State:NJ
Mailing Address - Zip Code:07110-3944
Mailing Address - Country:US
Mailing Address - Phone:718-501-0308
Mailing Address - Fax:
Practice Address - Street 1:479 HARTFORD DR
Practice Address - Street 2:
Practice Address - City:NUTLEY
Practice Address - State:NJ
Practice Address - Zip Code:07110-3944
Practice Address - Country:US
Practice Address - Phone:718-501-0308
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-31
Last Update Date:2021-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY294697207ZP0102X
390200000X
NJ25MA10973300207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program