Provider Demographics
NPI:1083687354
Name:WOLFROM, PAUL J (DO)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:J
Last Name:WOLFROM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6406
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93456-6406
Mailing Address - Country:US
Mailing Address - Phone:805-928-1731
Mailing Address - Fax:805-349-8160
Practice Address - Street 1:1010 MURRAY AVE
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93405-1806
Practice Address - Country:US
Practice Address - Phone:805-928-1731
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2016-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV1096207L00000X
CA20A6754207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002086785Medicaid
NV002086785Medicaid
CAW20A6754AMedicare PIN