Provider Demographics
NPI:1417138231
Name:SUSAN WOLF, M.D.
Entity Type:Organization
Organization Name:SUSAN WOLF, M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WOLF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:650-348-1242
Mailing Address - Street 1:100 S. ELLSWORTH AVENUE
Mailing Address - Street 2:SUITE 707
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94401-3939
Mailing Address - Country:US
Mailing Address - Phone:650-348-1242
Mailing Address - Fax:650-348-0788
Practice Address - Street 1:100 S. ELLSWORTH AVENUE
Practice Address - Street 2:SUITE 707
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94401-3939
Practice Address - Country:US
Practice Address - Phone:650-348-1242
Practice Address - Fax:650-348-0788
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUSAN WOLF, M.D.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-11-20
Last Update Date:2010-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA66326174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH34667Medicare UPIN