Provider Demographics
NPI:1457479560
Name:WOLF, IVAN L (MD)
Entity Type:Individual
Prefix:
First Name:IVAN
Middle Name:L
Last Name:WOLF
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 1:5074 PINE VALLEY DRIVE
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13066
Mailing Address - Country:US
Mailing Address - Phone:315-446-8129
Mailing Address - Fax:
Practice Address - Street 1:961 CANAL STREET
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-1287
Practice Address - Country:US
Practice Address - Phone:315-478-1977
Practice Address - Fax:315-475-2909
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1551702083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine