Provider Demographics
NPI:1497837272
Name:WOLF, JONATHAN (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
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 1:123 GROVE AVE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:CEDARHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11516
Mailing Address - Country:US
Mailing Address - Phone:516-295-0046
Mailing Address - Fax:516-295-7445
Practice Address - Street 1:123 GROVE AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:CEDARHURST
Practice Address - State:NY
Practice Address - Zip Code:11516
Practice Address - Country:US
Practice Address - Phone:516-295-0046
Practice Address - Fax:516-295-7445
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2009-08-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY19454212084P0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY52M831Medicare ID - Type Unspecified