Provider Demographics
NPI:1487644365
Name:WOLFUS, GEORGE MARIO (OD)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:MARIO
Last Name:WOLFUS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:DR
Other - First Name:GEORGE
Other - Middle Name:MARIO
Other - Last Name:WOLFUS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:17149 CITRONIA ST
Mailing Address - Street 2:
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91325-1931
Mailing Address - Country:US
Mailing Address - Phone:818-341-1190
Mailing Address - Fax:818-341-1190
Practice Address - Street 1:17149 CITRONIA ST
Practice Address - Street 2:
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91325-1931
Practice Address - Country:US
Practice Address - Phone:818-341-1190
Practice Address - Fax:818-341-1190
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-24
Last Update Date:2012-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4908T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0049080OtherBLUE SHIELD
CASD0049080Medicaid
CAOP4908TMedicare ID - Type Unspecified
CASD0049080Medicaid