Provider Demographics
NPI:1790748358
Name:WULFESTIEG, CARL W (MD)
Entity Type:Individual
Prefix:
First Name:CARL
Middle Name:W
Last Name:WULFESTIEG
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 1:22 PROSPECT ST
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:VT
Mailing Address - Zip Code:05091-1286
Mailing Address - Country:US
Mailing Address - Phone:802-457-7116
Mailing Address - Fax:
Practice Address - Street 1:22 PROSPECT ST
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:VT
Practice Address - Zip Code:05091-1286
Practice Address - Country:US
Practice Address - Phone:802-457-7116
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2011-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00017402207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1526706Medicaid
WA5208WUOtherBLUE SHIELD #
WAP00233197OtherRAILROAD MC #
WAUS4080197OtherAETNA SPECIALIST PIN
WAA08663Medicare UPIN
WAUS4080197OtherAETNA SPECIALIST PIN
WA8851029Medicare PIN