Provider Demographics
NPI:1619919305
Name:WOLLAK, ISTVAN DAVID (MD)
Entity Type:Individual
Prefix:
First Name:ISTVAN
Middle Name:DAVID
Last Name:WOLLAK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2120 EXETER RD
Mailing Address - Street 2:STE 250
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38138-3931
Mailing Address - Country:US
Mailing Address - Phone:901-767-5864
Mailing Address - Fax:901-767-6591
Practice Address - Street 1:401 SOUTHCREST CIR
Practice Address - Street 2:SUITE 212
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-6726
Practice Address - Country:US
Practice Address - Phone:662-349-0488
Practice Address - Fax:662-349-5974
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MS19168207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS19168OtherLICENSE NUMBER
TN103I295095Medicare PIN
MS19168OtherLICENSE NUMBER