Provider Demographics
NPI:1962470211
Name:WOLRAICH, MARK L (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:L
Last Name:WOLRAICH
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 1:1122 NE 13TH ST
Mailing Address - Street 2:ORI236
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73117-1039
Mailing Address - Country:US
Mailing Address - Phone:405-271-1515
Mailing Address - Fax:
Practice Address - Street 1:1100 NE 13TH ST
Practice Address - Street 2:CSC
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73117-1039
Practice Address - Country:US
Practice Address - Phone:405-271-6824
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK223502080P0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral Pediatrics