Provider Demographics
NPI:1801968797
Name:WOLFSON, FRED I (LAC)
Entity type:Individual
Prefix:
First Name:FRED
Middle Name:I
Last Name:WOLFSON
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10217 WHITE PELICAN WAY
Mailing Address - Street 2:105C
Mailing Address - City:NEW MARKET
Mailing Address - State:MD
Mailing Address - Zip Code:21774-2908
Mailing Address - Country:US
Mailing Address - Phone:301-788-9451
Mailing Address - Fax:
Practice Address - Street 1:340 PARK AVE
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21701-4931
Practice Address - Country:US
Practice Address - Phone:301-788-9451
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDU01417171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist