Provider Demographics
NPI:1023100492
Name:WOLF, J STUART JR (MD)
Entity type:Individual
Prefix:
First Name:J
Middle Name:STUART
Last Name:WOLF
Suffix:JR
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 1:1601 TRINITY ST, BLDG A
Mailing Address - Street 2:SUITE 704F
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78712
Mailing Address - Country:US
Mailing Address - Phone:512-324-7871
Mailing Address - Fax:512-324-7870
Practice Address - Street 1:1601 TRINITY ST, BLDG A
Practice Address - Street 2:SUITE 704F
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78712
Practice Address - Country:US
Practice Address - Phone:512-324-7871
Practice Address - Fax:512-324-7870
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR0159208800000X
MI4301067762208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX369729401Medicaid
MIF92842Medicare UPIN
MI3281380Medicaid