Provider Demographics
NPI:1407959836
Name:WOLKOV, SELLY (MD)
Entity Type:Individual
Prefix:
First Name:SELLY
Middle Name:
Last Name:WOLKOV
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1610 SHERIDAN ST
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33020-2306
Mailing Address - Country:US
Mailing Address - Phone:954-922-7400
Mailing Address - Fax:954-925-1327
Practice Address - Street 1:1610 SHERIDAN ST
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33020-2306
Practice Address - Country:US
Practice Address - Phone:954-922-7400
Practice Address - Fax:954-925-1327
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2015-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME51678207Q00000X
FLME0051678208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL268680500Medicaid
FL268680500Medicaid
FL14624YMedicare PIN