Provider Demographics
NPI:1619016391
Name:WOLLOCH, EMMANUELA HENRIETTE (MD)
Entity Type:Individual
Prefix:DR
First Name:EMMANUELA
Middle Name:HENRIETTE
Last Name:WOLLOCH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 NE 123RD ST
Mailing Address - Street 2:STE 415
Mailing Address - City:NORTH MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33181-2817
Mailing Address - Country:US
Mailing Address - Phone:305-935-8775
Mailing Address - Fax:305-705-2825
Practice Address - Street 1:1801 NE 123RD ST
Practice Address - Street 2:STE 415
Practice Address - City:NORTH MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33181-2817
Practice Address - Country:US
Practice Address - Phone:305-935-8775
Practice Address - Fax:305-705-2825
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2014-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 0059103207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL12495Medicare ID - Type Unspecified
FLE89620Medicare UPIN