Provider Demographics
NPI:1417913104
Name:WULFF, JONATHAN PAUL (DO)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:PAUL
Last Name:WULFF
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 269
Mailing Address - Street 2:
Mailing Address - City:EATON RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:48827
Mailing Address - Country:US
Mailing Address - Phone:517-663-4821
Mailing Address - Fax:517-663-5650
Practice Address - Street 1:1501 KYLE STREET
Practice Address - Street 2:
Practice Address - City:EATON RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:48827
Practice Address - Country:US
Practice Address - Phone:517-663-4821
Practice Address - Fax:517-663-5650
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-22
Last Update Date:2016-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIJW006732207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0152300115OtherBCBS
MI1388397Medicaid
MI0100445OtherPHYSICIAN HEALTH PLAN
MIP59044OtherBLUE CHOICE POS
MI4053314OtherAETNA
MI791063605OtherRR MEDICARE
MI5230011Medicare ID - Type Unspecified
F00564Medicare UPIN