Provider Demographics
NPI:1508301011
Name:WOLHAUPTER, NICHOLAS
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:WOLHAUPTER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6500 N SOCRUM LOOP RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33809-4179
Mailing Address - Country:US
Mailing Address - Phone:863-853-3331
Mailing Address - Fax:
Practice Address - Street 1:6500 N SOCRUM LOOP RD
Practice Address - Street 2:SUITE 100
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33809-4179
Practice Address - Country:US
Practice Address - Phone:863-853-3331
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-20
Last Update Date:2016-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9110064207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology