Provider Demographics
NPI:1467458000
Name:WOLFSON, JACK M (DO)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:M
Last Name:WOLFSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:10585 N TATUM BLVD
Mailing Address - Street 2:STE D135
Mailing Address - City:PARADISE VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85253-1073
Mailing Address - Country:US
Mailing Address - Phone:480-535-6844
Mailing Address - Fax:480-535-6845
Practice Address - Street 1:10585 N TATUM BLVD
Practice Address - Street 2:STE D135
Practice Address - City:PARADISE VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85253-1073
Practice Address - Country:US
Practice Address - Phone:480-535-6844
Practice Address - Fax:480-535-6845
Is Sole Proprietor?:No
Enumeration Date:2005-06-27
Last Update Date:2016-07-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ3761207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1Z6403OtherHEALTHNET
AZ060068481OtherRAILROAD MEDICARE
AZ25-01062OtherUNITED HEALTHCARE
AZ690257Medicaid
AZAZ0714780OtherBLUE CROSS BLUE SHIELD
AZ690257Medicaid
AZ1Z6403OtherHEALTHNET