Provider Demographics
NPI:1356616817
Name:WOLF, BRADLEY R (MD)
Entity type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:R
Last Name:WOLF
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 1:11877 MASON RD
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45249-4714
Mailing Address - Country:US
Mailing Address - Phone:513-774-0400
Mailing Address - Fax:513-774-0410
Practice Address - Street 1:11877 MASON RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45249-4714
Practice Address - Country:US
Practice Address - Phone:513-774-0400
Practice Address - Fax:513-774-0410
Is Sole Proprietor?:No
Enumeration Date:2012-03-16
Last Update Date:2012-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.052721174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist