Provider Demographics
NPI:1902848757
Name:WOLFSTHAL, SUSAN D (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:D
Last Name:WOLFSTHAL
Suffix:
Gender:F
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:PO BOX 64442
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-4442
Mailing Address - Country:US
Mailing Address - Phone:410-328-4388
Mailing Address - Fax:410-328-0267
Practice Address - Street 1:22 S GREENE ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1544
Practice Address - Country:US
Practice Address - Phone:410-328-4388
Practice Address - Fax:410-328-0267
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2014-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD25575207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD523974-02OtherBLUE CROSS/BLUE SHIELD
MD335961100Medicaid
MDB69853Medicare UPIN
MDS085J052Medicare PIN
MD110036749Medicare PIN