Provider Demographics
NPI:1962500322
Name:WOLFE, MARK WILLIAM (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:WILLIAM
Last Name:WOLFE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:25 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HYANNIS
Mailing Address - State:MA
Mailing Address - Zip Code:02601-3129
Mailing Address - Country:US
Mailing Address - Phone:508-778-1829
Mailing Address - Fax:508-778-0113
Practice Address - Street 1:25 MAIN ST
Practice Address - Street 2:
Practice Address - City:HYANNIS
Practice Address - State:MA
Practice Address - Zip Code:02601-3129
Practice Address - Country:US
Practice Address - Phone:508-778-1829
Practice Address - Fax:508-778-0113
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2009-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA72524207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA000000030686OtherBOSTON MEDICAL CENTER
MA1962500322OtherUNICARE
MA300157OtherHARVARD PILGRIM
MA1962500322OtherNETWORK HEALTH
MA3155595Medicaid
MA060058507OtherMEDICARE ID
MA072524OtherTUFTS
11091976OtherCAQH
MA25-00639OtherUNITED HEALTHCARE
MAJ16944OtherBLUE CROSS BLUE SHIELD
MA1962500322OtherGREAT WEST HEALTHCARE
MA22772959OtherAETNA
MA3094730-001OtherCIGNA
MAS017060OtherTRICARE
MAJ16944OtherBLUE CROSS BLUE SHIELD
A21317Medicare ID - Type Unspecified