Provider Demographics
NPI:1790762417
Name:WOLFE, RICKY DAVID (MD)
Entity Type:Individual
Prefix:
First Name:RICKY
Middle Name:DAVID
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 1:1530 N LIMESTONE ST
Mailing Address - Street 2:
Mailing Address - City:GAFFNEY
Mailing Address - State:SC
Mailing Address - Zip Code:29340
Mailing Address - Country:US
Mailing Address - Phone:864-487-1603
Mailing Address - Fax:864-487-1626
Practice Address - Street 1:1530 N LIMESTONE ST
Practice Address - Street 2:
Practice Address - City:GAFFNEY
Practice Address - State:SC
Practice Address - Zip Code:29340
Practice Address - Country:US
Practice Address - Phone:864-487-1603
Practice Address - Fax:864-487-1626
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-22
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC14003207ZP0101X
NC207ZP0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5901767Medicaid
SCQ41705Medicaid
GA00708606AMedicaid
GA00708606AMedicaid
SCQ41705Medicaid
NC2045524Medicare PIN