Provider Demographics
NPI:1558432583
Name:WOLLFARTH, JEROME PAUL (PT)
Entity Type:Individual
Prefix:MR
First Name:JEROME
Middle Name:PAUL
Last Name:WOLLFARTH
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22056 SPRING CLOVER LN
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70435-6738
Mailing Address - Country:US
Mailing Address - Phone:985-893-2845
Mailing Address - Fax:985-893-2654
Practice Address - Street 1:340 FALCONER DR
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433
Practice Address - Country:US
Practice Address - Phone:985-893-2845
Practice Address - Fax:985-893-2654
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2007-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA06427174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA4H961CP75Medicare PIN