Provider Demographics
NPI:1720191729
Name:WOLF, PAUL SERGEI (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:SERGEI
Last Name:WOLF
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 1:1189 E HERNDON AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-3167
Mailing Address - Country:US
Mailing Address - Phone:559-434-5639
Mailing Address - Fax:
Practice Address - Street 1:1189 E HERNDON AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-3167
Practice Address - Country:US
Practice Address - Phone:559-434-5639
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2007-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA91087208000000X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAMD 073534 LOtherMEDICAL LICENSE
PAMD 073534 LOtherMEDICAL LICENSE
CA00A910870Medicare ID - Type Unspecified