Provider Demographics
NPI:1497974190
Name:WOLF PODIATRY CORP
Entity Type:Organization
Organization Name:WOLF PODIATRY CORP
Other - Org Name:CLIFFORD WOLF
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:CLIFFORD
Authorized Official - Middle Name:J
Authorized Official - Last Name:WOLF
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:858-451-2151
Mailing Address - Street 1:12630 MONTE VISTA RD STE 101
Mailing Address - Street 2:
Mailing Address - City:POWAY
Mailing Address - State:CA
Mailing Address - Zip Code:92064-2526
Mailing Address - Country:US
Mailing Address - Phone:858-451-2151
Mailing Address - Fax:858-451-3097
Practice Address - Street 1:12630 MONTE VISTA RD STE 101
Practice Address - Street 2:
Practice Address - City:POWAY
Practice Address - State:CA
Practice Address - Zip Code:92064-2526
Practice Address - Country:US
Practice Address - Phone:858-451-2151
Practice Address - Fax:858-451-3097
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE2161213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E21613Medicaid
CA1124085006OtherNPI TYPE1
CA1124085006OtherNPI TYPE1
CAE2161Medicare ID - Type UnspecifiedPROVIDER
CA4239130001Medicare NSC