Provider Demographics
NPI:1184649634
Name:WOLK, JEFFREY M (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:M
Last Name:WOLK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3410 CANYON DE FLORES
Mailing Address - Street 2:SUITE B
Mailing Address - City:SIERRA VISTA
Mailing Address - State:AZ
Mailing Address - Zip Code:85650-5372
Mailing Address - Country:US
Mailing Address - Phone:520-459-4477
Mailing Address - Fax:520-803-9572
Practice Address - Street 1:3410 CANYON DE FLORES
Practice Address - Street 2:SUITE B
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85650-5372
Practice Address - Country:US
Practice Address - Phone:520-459-4477
Practice Address - Fax:520-803-9572
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2011-02-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ33318208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ890790Medicaid
AZ890790Medicaid
AZE62801Medicare UPIN