Provider Demographics
NPI:1104932649
Name:WOLK, LAWRENCE I (MD)
Entity type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:I
Last Name:WOLK
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 1:9197 GRANT ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:THORNTON
Mailing Address - State:CO
Mailing Address - Zip Code:80229-4361
Mailing Address - Country:US
Mailing Address - Phone:303-869-2173
Mailing Address - Fax:
Practice Address - Street 1:9197 GRANT ST
Practice Address - Street 2:SUITE 100
Practice Address - City:THORNTON
Practice Address - State:CO
Practice Address - Zip Code:80229-4361
Practice Address - Country:US
Practice Address - Phone:303-869-2173
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2012-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO31073208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01310739Medicaid