Provider Demographics
NPI:1790941334
Name:WOLVERTON, WAYNE OLIVER (DO)
Entity Type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:OLIVER
Last Name:WOLVERTON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5410 MARYLAND WAY STE 300
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-5339
Mailing Address - Country:US
Mailing Address - Phone:615-377-5602
Mailing Address - Fax:615-271-1692
Practice Address - Street 1:200 BRULE ST
Practice Address - Street 2:
Practice Address - City:FORT KNOX
Practice Address - State:KY
Practice Address - Zip Code:40121-6100
Practice Address - Country:US
Practice Address - Phone:502-626-9789
Practice Address - Fax:502-624-0482
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-04
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY04033207KA0200X, 207R00000X
GAVAD 000207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD 000Medicare UPIN