Provider Demographics
NPI:1861470791
Name:WOLF, KARL KONRAD (MD)
Entity Type:Individual
Prefix:DR
First Name:KARL
Middle Name:KONRAD
Last Name:WOLF
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1262 E NORTH ST
Mailing Address - Street 2:
Mailing Address - City:MANTECA
Mailing Address - State:CA
Mailing Address - Zip Code:95336-4962
Mailing Address - Country:US
Mailing Address - Phone:209-823-7646
Mailing Address - Fax:209-824-5374
Practice Address - Street 1:1262 E NORTH ST
Practice Address - Street 2:
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95336-4962
Practice Address - Country:US
Practice Address - Phone:209-823-7646
Practice Address - Fax:209-824-5374
Is Sole Proprietor?:No
Enumeration Date:2005-12-30
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA24460207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA23990Medicare UPIN
CA00A244600Medicare PIN