Provider Demographics
NPI:1558478586
Name:WOLFE, RUSSELL M (MD)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:M
Last Name:WOLFE
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:PO BOX 39209
Mailing Address - Street 2:
Mailing Address - City:FT. LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33339
Mailing Address - Country:US
Mailing Address - Phone:954-851-9966
Mailing Address - Fax:954-318-7360
Practice Address - Street 1:3419 JOHNSON ST
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021
Practice Address - Country:US
Practice Address - Phone:954-989-2800
Practice Address - Fax:954-989-2873
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL62097207W00000X
FLME0062097207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL180031939OtherRAILROAD MEDICARE
FL2504301OtherEMPLOYERS MUTUAL
FL15197OtherBCBS OF FL
FL1820665OtherCIGNA
FL2078933OtherAETNA
FL370552800Medicaid
FL100817OtherAV MED
FL2078933OtherAETNA
FLF30665Medicare UPIN
15197YMedicare PIN