Provider Demographics
NPI:1942206727
Name:WOLF, ERICH W JR (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:ERICH
Middle Name:W
Last Name:WOLF
Suffix:JR
Gender:M
Credentials:MD, PHD
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 1786
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70602-1786
Mailing Address - Country:US
Mailing Address - Phone:337-478-9653
Mailing Address - Fax:337-474-0988
Practice Address - Street 1:1614 WOLF CIR
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-2348
Practice Address - Country:US
Practice Address - Phone:337-478-9653
Practice Address - Fax:337-474-0988
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-24
Last Update Date:2010-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA021935207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5CA84OtherGROUP MEDICARE #
LA1567949Medicaid
LA5CA84OtherGROUP MEDICARE #
LA1567949Medicaid