Provider Demographics
NPI:1063691301
Name:KEVIN JAY WOLF
Entity type:Organization
Organization Name:KEVIN JAY WOLF
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:WOLF
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:919-583-9788
Mailing Address - Street 1:407 N HERMAN ST
Mailing Address - Street 2:
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27530-3816
Mailing Address - Country:US
Mailing Address - Phone:919-583-9788
Mailing Address - Fax:919-583-9790
Practice Address - Street 1:407 N HERMAN ST
Practice Address - Street 2:
Practice Address - City:GOLDSBORO
Practice Address - State:NC
Practice Address - Zip Code:27530-3816
Practice Address - Country:US
Practice Address - Phone:919-583-9788
Practice Address - Fax:919-583-9790
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-02
Last Update Date:2014-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC357213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0818HOtherBCBS
NC890818HMedicaid
NC2432706Medicare PIN
NC0948690001Medicare NSC
NC0818HOtherBCBS