Provider Demographics
NPI:1760628960
Name:WOLK, DERRICK A (MPT)
Entity Type:Individual
Prefix:MR
First Name:DERRICK
Middle Name:A
Last Name:WOLK
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1155 HAZEL LN
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63640-1920
Mailing Address - Country:US
Mailing Address - Phone:573-756-2937
Mailing Address - Fax:573-756-2939
Practice Address - Street 1:109 VIERSE DR
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MO
Practice Address - Zip Code:63640-1323
Practice Address - Country:US
Practice Address - Phone:573-756-2937
Practice Address - Fax:573-756-2939
Is Sole Proprietor?:No
Enumeration Date:2008-12-18
Last Update Date:2019-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008032045225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO138770001Medicare PIN