Provider Demographics
NPI:1306015045
Name:GARY WOLF
Entity Type:Organization
Organization Name:GARY WOLF
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:WOLF
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:413-283-2946
Mailing Address - Street 1:1140 THORNDIKE ST
Mailing Address - Street 2:PO BOX 909
Mailing Address - City:PALMER
Mailing Address - State:MA
Mailing Address - Zip Code:01069-1509
Mailing Address - Country:US
Mailing Address - Phone:413-283-2946
Mailing Address - Fax:413-283-3631
Practice Address - Street 1:1140 THORNDIKE ST
Practice Address - Street 2:
Practice Address - City:PALMER
Practice Address - State:MA
Practice Address - Zip Code:01069-1509
Practice Address - Country:US
Practice Address - Phone:413-283-2946
Practice Address - Fax:413-283-3631
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-27
Last Update Date:2008-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2853332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0338656Medicaid
MA0338656Medicaid
MA0433630002Medicare NSC
MA192958Medicare PIN