Provider Demographics
NPI:1760404529
Name:WOLFSON, YAN (MD)
Entity Type:Individual
Prefix:MR
First Name:YAN
Middle Name:
Last Name:WOLFSON
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 1:2675 WINKLER AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-9342
Mailing Address - Country:US
Mailing Address - Phone:877-856-3774
Mailing Address - Fax:
Practice Address - Street 1:435 2ND ST NE
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33881-4103
Practice Address - Country:US
Practice Address - Phone:863-288-0942
Practice Address - Fax:863-288-0943
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY187897208800000X
FLME153746208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL114650000Medicaid
402221Medicare ID - Type Unspecified
G24585Medicare UPIN
402222Medicare ID - Type Unspecified