Provider Demographics
NPI:1942567243
Name:WOLFORD, BRENT (MD)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:
Last Name:WOLFORD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4200 UNIVERSITY AVENUE
Mailing Address - Street 2:STE 104
Mailing Address - City:CLIVE
Mailing Address - State:IA
Mailing Address - Zip Code:50266
Mailing Address - Country:US
Mailing Address - Phone:515-961-0453
Mailing Address - Fax:515-961-2714
Practice Address - Street 1:12368 STRATFORD DR STE 300
Practice Address - Street 2:
Practice Address - City:CLIVE
Practice Address - State:IA
Practice Address - Zip Code:50325-8149
Practice Address - Country:US
Practice Address - Phone:515-226-8408
Practice Address - Fax:515-226-8408
Is Sole Proprietor?:No
Enumeration Date:2012-04-12
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCDR.00013252085R0202X
IAMD-443222085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology