Provider Demographics
NPI:1801960901
Name:ERLICH, WOLF J (MD)
Entity type:Individual
Prefix:
First Name:WOLF
Middle Name:J
Last Name:ERLICH
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 1:950 YALE AVE
Mailing Address - Street 2:STE 39
Mailing Address - City:WALLINGFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06492
Mailing Address - Country:US
Mailing Address - Phone:203-679-4296
Mailing Address - Fax:203-679-4299
Practice Address - Street 1:950 YALE AVE
Practice Address - Street 2:STE 39
Practice Address - City:WALLINGFORD
Practice Address - State:CT
Practice Address - Zip Code:06492
Practice Address - Country:US
Practice Address - Phone:203-679-4296
Practice Address - Fax:203-679-4299
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT033341207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT333410OtherCONNECTICARE
CT010033341CT02OtherBCBS CT
CT001333418Medicaid
CT010033341CT02OtherBCBS CT
CT110005881Medicare ID - Type Unspecified