Provider Demographics
NPI:1205895216
Name:WOLFF, MIRELA
Entity type:Individual
Prefix:
First Name:MIRELA
Middle Name:
Last Name:WOLFF
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MIRELA
Other - Middle Name:
Other - Last Name:MIZUMSCHI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:365 MONTAUK AVE
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:CT
Mailing Address - Zip Code:06320-4700
Mailing Address - Country:US
Mailing Address - Phone:860-271-4364
Mailing Address - Fax:860-444-5114
Practice Address - Street 1:365 MONTAUK AVE
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-4700
Practice Address - Country:US
Practice Address - Phone:860-271-4364
Practice Address - Fax:860-444-5114
Is Sole Proprietor?:No
Enumeration Date:2006-03-20
Last Update Date:2013-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT043337207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTI45093Medicare UPIN