Provider Demographics
NPI:1124105085
Name:WULFF, KENNETH R (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:R
Last Name:WULFF
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 1:1503 SPRING HILL RD
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94952-9305
Mailing Address - Country:US
Mailing Address - Phone:707-559-3895
Mailing Address - Fax:
Practice Address - Street 1:1503 SPRING HILL RD
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94952-9305
Practice Address - Country:US
Practice Address - Phone:707-559-3895
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG326832084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G326830Medicaid
F09237Medicare UPIN
00G326830Medicare ID - Type Unspecified