Provider Demographics
NPI:1396953527
Name:RICHARD WOLFSON, PC
Entity type:Organization
Organization Name:RICHARD WOLFSON, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:CRAIG
Authorized Official - Last Name:WOLFSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:602-741-8997
Mailing Address - Street 1:4929 E VILLA RITA DR
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85254-7562
Mailing Address - Country:US
Mailing Address - Phone:602-741-8997
Mailing Address - Fax:
Practice Address - Street 1:4045 E BELL RD
Practice Address - Street 2:111
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-2236
Practice Address - Country:US
Practice Address - Phone:602-795-1985
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-20
Last Update Date:2008-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ23377207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZF05355Medicaid