Provider Demographics
NPI:1417362864
Name:WOLFE, JONATHAN DAVID (OD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:DAVID
Last Name:WOLFE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 ANDERSON AVE
Mailing Address - Street 2:
Mailing Address - City:SCARSDALE
Mailing Address - State:NY
Mailing Address - Zip Code:10583-5547
Mailing Address - Country:US
Mailing Address - Phone:646-341-0282
Mailing Address - Fax:
Practice Address - Street 1:873 SAW MILL RIVER ROAD
Practice Address - Street 2:
Practice Address - City:ARDSLEY
Practice Address - State:NY
Practice Address - Zip Code:10502-1104
Practice Address - Country:US
Practice Address - Phone:914-222-4694
Practice Address - Fax:914-222-5299
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-24
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV008162-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03992101Medicaid