Provider Demographics
NPI:1629027164
Name:WOLFF, ROBERT T (DC)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:T
Last Name:WOLFF
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2150 ED F DAVIS RD
Mailing Address - Street 2:
Mailing Address - City:DURANT
Mailing Address - State:OK
Mailing Address - Zip Code:74701-1053
Mailing Address - Country:US
Mailing Address - Phone:580-931-3343
Mailing Address - Fax:580-931-3303
Practice Address - Street 1:2150 ED F DAVIS RD
Practice Address - Street 2:
Practice Address - City:DURANT
Practice Address - State:OK
Practice Address - Zip Code:74701-1053
Practice Address - Country:US
Practice Address - Phone:580-931-3343
Practice Address - Fax:580-931-3303
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-10
Last Update Date:2014-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3757111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK249531502Medicare PIN
OK900522298Medicare ID - Type UnspecifiedGROUP/CLINIC PROVIDER #