Provider Demographics
NPI:1194876235
Name:WOLF, DONALD KIRK (PT)
Entity type:Individual
Prefix:
First Name:DONALD
Middle Name:KIRK
Last Name:WOLF
Suffix:
Gender:M
Credentials:PT
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 1409
Mailing Address - Street 2:
Mailing Address - City:EAGLE POINT
Mailing Address - State:OR
Mailing Address - Zip Code:97524-1409
Mailing Address - Country:US
Mailing Address - Phone:541-830-0914
Mailing Address - Fax:
Practice Address - Street 1:158 MAIN
Practice Address - Street 2:
Practice Address - City:EAGLE POINT
Practice Address - State:OR
Practice Address - Zip Code:97524
Practice Address - Country:US
Practice Address - Phone:541-830-0914
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1003225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR211144Medicaid
OR211144Medicaid