Provider Demographics
NPI:1841358587
Name:WOLFSON, IVAN S (MD)
Entity type:Individual
Prefix:
First Name:IVAN
Middle Name:S
Last Name:WOLFSON
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 1:375 ALLENS AVE
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02905-5010
Mailing Address - Country:US
Mailing Address - Phone:401-444-0400
Mailing Address - Fax:401-444-0468
Practice Address - Street 1:375 ALLENS AVE
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02905-5010
Practice Address - Country:US
Practice Address - Phone:401-444-0400
Practice Address - Fax:401-444-0468
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD8535207Q00000X, 207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine