Provider Demographics
NPI:1407488182
Name:TOM WULF MD LLC
Entity Type:Organization
Organization Name:TOM WULF MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:WULF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:575-208-7795
Mailing Address - Street 1:313 W COUNTRY CLUB RD STE 15
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-5804
Mailing Address - Country:US
Mailing Address - Phone:575-208-7795
Mailing Address - Fax:575-208-7785
Practice Address - Street 1:607 W COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-5211
Practice Address - Country:US
Practice Address - Phone:575-208-7795
Practice Address - Fax:575-208-7785
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-10
Last Update Date:2020-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No251G00000XAgenciesHospice Care, Community BasedGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM42637716Medicaid