Provider Demographics
NPI:1396740064
Name:WOLCOTT, JOHN K (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:K
Last Name:WOLCOTT
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 1:5174 FM 1252 W
Mailing Address - Street 2:
Mailing Address - City:KILGORE
Mailing Address - State:TX
Mailing Address - Zip Code:75662-1961
Mailing Address - Country:US
Mailing Address - Phone:903-986-1901
Mailing Address - Fax:903-984-6151
Practice Address - Street 1:5174 FM 1252 W
Practice Address - Street 2:
Practice Address - City:KILGORE
Practice Address - State:TX
Practice Address - Zip Code:75662-1961
Practice Address - Country:US
Practice Address - Phone:903-986-1901
Practice Address - Fax:903-984-6151
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH2190207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX133713108Medicaid
TX133713108Medicaid
TX8L7399Medicare PIN