Provider Demographics
NPI:1275639874
Name:WOLF, BRUCE (DO)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:
Last Name:WOLF
Suffix:
Gender:M
Credentials:DO
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Mailing Address - Street 1:804 SERVICE RD STE A109B
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48824-7015
Mailing Address - Country:US
Mailing Address - Phone:517-975-8930
Mailing Address - Fax:517-337-4985
Practice Address - Street 1:3220 DISCOVERY DR STE 100
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48910-7015
Practice Address - Country:US
Practice Address - Phone:517-975-8930
Practice Address - Fax:517-337-4985
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2023-07-06
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI5101012460174400000X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1275639874Medicaid