Provider Demographics
NPI:1689636557
Name:WOLF, FAWN MELANIE (MD)
Entity Type:Individual
Prefix:
First Name:FAWN
Middle Name:MELANIE
Last Name:WOLF
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:FAWN
Other - Middle Name:MELANIE
Other - Last Name:JUVINALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:9155 SW BERNES RD.
Mailing Address - Street 2:SUITE 638
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225
Mailing Address - Country:US
Mailing Address - Phone:503-216-7000
Mailing Address - Fax:503-216-6940
Practice Address - Street 1:9155 SW BERNES RD.
Practice Address - Street 2:SUITE 638
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225
Practice Address - Country:US
Practice Address - Phone:503-216-7000
Practice Address - Fax:503-216-6940
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD25195207R00000X, 207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR277859Medicaid
ORI35350Medicare UPIN
OR277859Medicaid