Provider Demographics
NPI:1740324698
Name:WOLFE, BOBBY JOE JR
Entity type:Individual
Prefix:
First Name:BOBBY
Middle Name:JOE
Last Name:WOLFE
Suffix:JR
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 1:100 TAMBERLINE ST
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39042-3164
Mailing Address - Country:US
Mailing Address - Phone:601-825-2141
Mailing Address - Fax:
Practice Address - Street 1:100 TAMBERLINE ST
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39042-3164
Practice Address - Country:US
Practice Address - Phone:601-825-2141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2011-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS070762083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00123676Medicaid
MSE05457Medicare UPIN
MS010000208Medicare ID - Type UnspecifiedBOBBY JOE WOLFE