Provider Demographics
NPI:1205871142
Name:MARC D. WOLFSOHN MD INC
Entity type:Organization
Organization Name:MARC D. WOLFSOHN MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARC
Authorized Official - Middle Name:D
Authorized Official - Last Name:WOLFSOHN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-484-8558
Mailing Address - Street 1:P.O. BOX 5457
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93403
Mailing Address - Country:US
Mailing Address - Phone:805-484-8558
Mailing Address - Fax:805-484-3099
Practice Address - Street 1:1100 PASEO CAMARILLO
Practice Address - Street 2:
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93010
Practice Address - Country:US
Practice Address - Phone:805-484-8558
Practice Address - Fax:805-484-3099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-17
Last Update Date:2011-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG34454207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G344540Medicaid
CAW14902Medicare ID - Type Unspecified