Provider Demographics
NPI:1205836079
Name:WOLFGANG, MARIE C (MD)
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:C
Last Name:WOLFGANG
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 1:1 CEDAR AVE
Mailing Address - Street 2:
Mailing Address - City:SEAFORD
Mailing Address - State:DE
Mailing Address - Zip Code:19973-3300
Mailing Address - Country:US
Mailing Address - Phone:302-629-2366
Mailing Address - Fax:302-629-6570
Practice Address - Street 1:1 CEDAR AVE
Practice Address - Street 2:
Practice Address - City:SEAFORD
Practice Address - State:DE
Practice Address - Zip Code:19973-3300
Practice Address - Country:US
Practice Address - Phone:302-629-2366
Practice Address - Fax:302-629-6570
Is Sole Proprietor?:No
Enumeration Date:2005-07-22
Last Update Date:2014-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC10003884207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0000405701Medicaid
110160594OtherRR MEDICARE
4364105OtherAETNA
F27386Medicare UPIN
DE001249Medicare PIN