Provider Demographics
NPI:1396783080
Name:WOLF, JACOB MARVIN (MD)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:MARVIN
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:PO BOX 746638
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6638
Mailing Address - Country:US
Mailing Address - Phone:904-202-2092
Mailing Address - Fax:904-376-4075
Practice Address - Street 1:520 A1A N STE 101
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32082-2260
Practice Address - Country:US
Practice Address - Phone:904-273-6900
Practice Address - Fax:904-390-7479
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2024-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME149672207Q00000X, 207Q00000X
OH35-07-7375-W207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2250326Medicaid
OH4050227Medicare PIN
W04050229Medicare PIN