Provider Demographics
NPI:1760486021
Name:WOLFE, RANDY L (MD)
Entity Type:Individual
Prefix:DR
First Name:RANDY
Middle Name:L
Last Name:WOLFE
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:PO BOX 1395
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42302-1395
Mailing Address - Country:US
Mailing Address - Phone:270-688-4325
Mailing Address - Fax:
Practice Address - Street 1:1325 TRIPLETT ST
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-3163
Practice Address - Country:US
Practice Address - Phone:270-688-4325
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-02
Last Update Date:2007-07-09
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-03-28
Provider Licenses
StateLicense IDTaxonomies
KY18397207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64183973Medicaid
KY000000198726OtherANTHEM BLUE CROSS/SHIELD
KY65934259Medicaid
KY7513462OtherCIGNA
KY50002978OtherPASSPORT
KYC64364Medicare UPIN
KY1879601Medicare ID - Type Unspecified