Provider Demographics
NPI:1396719696
Name:WOLKSTEIN, JILL LISA (DO)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:LISA
Last Name:WOLKSTEIN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:JILL
Other - Middle Name:LISA
Other - Last Name:DALBA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:6716 NW 11TH PLACE
Mailing Address - Street 2:STE 200
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32605-4215
Mailing Address - Country:US
Mailing Address - Phone:352-331-9729
Mailing Address - Fax:352-338-7140
Practice Address - Street 1:6716 NW 11TH PLACE
Practice Address - Street 2:STE 200
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32605-4215
Practice Address - Country:US
Practice Address - Phone:352-331-9729
Practice Address - Fax:352-331-0136
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2022-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS86322085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP01215410OtherRAILROAD MEDICARE
FLP01196235OtherRAILROAD MEDICARE
FL015061900Medicaid
FL13581OtherBCBS FL
FLP01196235OtherRAILROAD MEDICARE
FL13581WMedicare PIN
FL015061900Medicaid
FLP01215410OtherRAILROAD MEDICARE
FL13581OtherBCBS FL
FL264260300Medicaid