Provider Demographics
NPI:1679561286
Name:WOLK, PETER J (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:J
Last Name:WOLK
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 1:198 COHASSET RD
Mailing Address - Street 2:
Mailing Address - City:CHICO
Mailing Address - State:CA
Mailing Address - Zip Code:95926-2202
Mailing Address - Country:US
Mailing Address - Phone:530-342-0123
Mailing Address - Fax:530-342-6475
Practice Address - Street 1:198 COHASSET RD
Practice Address - Street 2:
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95926-2202
Practice Address - Country:US
Practice Address - Phone:530-342-0123
Practice Address - Fax:530-342-6475
Is Sole Proprietor?:No
Enumeration Date:2005-10-07
Last Update Date:2011-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG34455207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0014100Medicaid
CAA45932Medicare UPIN
CAZZZ1658OZMedicare ID - Type UnspecifiedGROUP NUMBER