Provider Demographics
NPI:1154424596
Name:WOLFF, RICHARD MARK (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:MARK
Last Name:WOLFF
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 1:205 BRESEE ST
Mailing Address - Street 2:
Mailing Address - City:DONALSONVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:39845
Mailing Address - Country:US
Mailing Address - Phone:229-524-1307
Mailing Address - Fax:229-524-6268
Practice Address - Street 1:205 BRESEE ST
Practice Address - Street 2:
Practice Address - City:DONALSONVILLE
Practice Address - State:GA
Practice Address - Zip Code:39845
Practice Address - Country:US
Practice Address - Phone:229-524-1307
Practice Address - Fax:229-524-6268
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-07
Last Update Date:2008-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME36950208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL202228700OtherUNITED HEALTHCARE
FL95515OtherBSF
FL065505800Medicaid
FL222439OtherHEALTHEASE
FL202228700OtherHUMANA
FL008197OtherAVMED
FL202228700OtherTRICARE
FL222439OtherSTAYWELL
FL4200788OtherAETNA
FL065505800Medicaid