Provider Demographics
NPI:1942362090
Name:WOLFGANG, GARY
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:WOLFGANG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:573 BROOKOVER AVE
Mailing Address - Street 2:
Mailing Address - City:ZANESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43701-2101
Mailing Address - Country:US
Mailing Address - Phone:740-454-0366
Mailing Address - Fax:740-454-3790
Practice Address - Street 1:573 BROOKOVER AVE
Practice Address - Street 2:
Practice Address - City:ZANESVILLE
Practice Address - State:OH
Practice Address - Zip Code:43701-2101
Practice Address - Country:US
Practice Address - Phone:740-454-0366
Practice Address - Fax:740-454-3790
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHY281337OtherHEALTHPLAN
OH000000249349OtherANTHEM