Provider Demographics
NPI:1619995693
Name:WOLF, GARY D (DO)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:D
Last Name:WOLF
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 E BROAD ST
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-1709
Mailing Address - Country:US
Mailing Address - Phone:817-473-6750
Mailing Address - Fax:817-477-1708
Practice Address - Street 1:501 E BROAD ST
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-1709
Practice Address - Country:US
Practice Address - Phone:817-473-6750
Practice Address - Fax:817-477-1708
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2012-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE9029207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX120602106Medicaid
TX120602105Medicaid
TX120602108Medicaid
TX120602107Medicaid
TX8C9786Medicare ID - Type Unspecified
TXTXB121933Medicare PIN
TXTXB122584Medicare PIN
TX120602108Medicaid
TXC23701Medicare UPIN