Provider Demographics
NPI:1437143237
Name:WOLK, LARRY (MD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:
Last Name:WOLK
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 1:1 DIAMOND HILL RD
Mailing Address - Street 2:
Mailing Address - City:BERKELEY HEIGHTS
Mailing Address - State:NJ
Mailing Address - Zip Code:07922-2104
Mailing Address - Country:US
Mailing Address - Phone:908-273-4300
Mailing Address - Fax:
Practice Address - Street 1:970 HOOPER AVE # 2
Practice Address - Street 2:
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08753-8319
Practice Address - Country:US
Practice Address - Phone:732-228-4146
Practice Address - Fax:732-504-7104
Is Sole Proprietor?:No
Enumeration Date:2005-09-07
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD020175E207R00000X, 208600000X
NJ25MA04463400208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000966226Medicaid
PA0096622605OtherAMERICHOICE
PA10880OtherBRAVO ELDER HEALTH
PA0030929000OtherINDEPENDENCE BLUE CROSS
PA13361OtherHEALTH PARTNERS
PA20018648OtherRR MEDICARE
PA20018648OtherRR MEDICARE
PA10880OtherBRAVO ELDER HEALTH
PA0096622605OtherAMERICHOICE