Provider Demographics
NPI:1396889366
Name:WULFORST, MICHAEL JOSEPH
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:JOSEPH
Last Name:WULFORST
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 STEWART ST
Mailing Address - Street 2:
Mailing Address - City:EAST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11730-1712
Mailing Address - Country:US
Mailing Address - Phone:631-224-1266
Mailing Address - Fax:631-224-1266
Practice Address - Street 1:245 UNION AVE
Practice Address - Street 2:
Practice Address - City:HOLBROOK
Practice Address - State:NY
Practice Address - Zip Code:11741-1800
Practice Address - Country:US
Practice Address - Phone:631-471-1335
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000486-12255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer