Provider Demographics
NPI:1912232166
Name:BRAD A WOLFSON M D A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:BRAD A WOLFSON M D A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DORIS
Authorized Official - Middle Name:OLIVIA
Authorized Official - Last Name:EBERHARDT
Authorized Official - Suffix:
Authorized Official - Credentials:CPC, CUC
Authorized Official - Phone:760-320-6005
Mailing Address - Street 1:555 E TACHEVAH DR
Mailing Address - Street 2:SUITE 2 WEST 101
Mailing Address - City:PALM SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92262-5750
Mailing Address - Country:US
Mailing Address - Phone:760-320-6005
Mailing Address - Fax:760-323-5786
Practice Address - Street 1:555 E TACHEVAH DR STE 2
Practice Address - Street 2:
Practice Address - City:PALM SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92262-5750
Practice Address - Country:US
Practice Address - Phone:760-320-6005
Practice Address - Fax:760-323-5786
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-06
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG61080208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG61080OtherCA MEDICAL LICENSE
CA00G610801Medicaid
CA00G610801Medicaid
00G610800Medicare PIN