Provider Demographics
NPI:1417055948
Name:WOLFE, JACK C (MD)
Entity Type:Individual
Prefix:MR
First Name:JACK
Middle Name:C
Last Name:WOLFE
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1625 E MAIN ST
Mailing Address - Street 2:STE. 100
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92021-5211
Mailing Address - Country:US
Mailing Address - Phone:619-442-9896
Mailing Address - Fax:619-442-2245
Practice Address - Street 1:1625 E MAIN ST
Practice Address - Street 2:STE. 100
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92021-5211
Practice Address - Country:US
Practice Address - Phone:619-442-9896
Practice Address - Fax:619-442-2245
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2015-05-28
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAG29972207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G299720Medicaid
CA00G299720Medicaid
CAA44243Medicare UPIN