Provider Demographics
NPI:1740257641
Name:WOLFORD, JOHN LELAND JR (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:LELAND
Last Name:WOLFORD
Suffix:JR
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 3239
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29502-3239
Mailing Address - Country:US
Mailing Address - Phone:843-777-7120
Mailing Address - Fax:843-777-7102
Practice Address - Street 1:401 E CHEVES ST
Practice Address - Street 2:SUITE 301
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29506-2615
Practice Address - Country:US
Practice Address - Phone:843-777-7166
Practice Address - Fax:843-777-7167
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC21156207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCT49873Medicaid
SCT49873Medicaid