Provider Demographics
NPI:1396730503
Name:WOLFSON, JEFFREY ALAN (MD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:ALAN
Last Name:WOLFSON
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 1:1000 E PARIS AVE SE
Mailing Address - Street 2:STE 200
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-3691
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1000 E PARIS AVE SE
Practice Address - Street 2:STE 200
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-3691
Practice Address - Country:US
Practice Address - Phone:616-949-8554
Practice Address - Fax:616-949-6557
Is Sole Proprietor?:No
Enumeration Date:2005-09-14
Last Update Date:2008-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301063821207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI060029311OtherMEDICARE RRR
MI103045795Medicaid
MI103045795Medicaid
MID10242Medicare UPIN