Provider Demographics
NPI:1861489874
Name:WOLF, DAVID A (OD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:A
Last Name:WOLF
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15480 BOONES FERRY RD
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-3429
Mailing Address - Country:US
Mailing Address - Phone:503-635-1458
Mailing Address - Fax:
Practice Address - Street 1:15480 BOONES FERRY RD
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-3429
Practice Address - Country:US
Practice Address - Phone:503-635-1458
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1670ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR119033Medicare ID - Type Unspecified
ORU47133Medicare UPIN