Provider Demographics
NPI:1215993068
Name:WOLKE, ANITA (MD)
Entity type:Individual
Prefix:
First Name:ANITA
Middle Name:
Last Name:WOLKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:11440 COMMERCE PARK DR
Mailing Address - Street 2:LL4
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20191-1555
Mailing Address - Country:US
Mailing Address - Phone:703-766-2650
Mailing Address - Fax:703-766-2654
Practice Address - Street 1:11440 COMMERCE PARK DR
Practice Address - Street 2:LL4
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20191-1555
Practice Address - Country:US
Practice Address - Phone:703-766-2650
Practice Address - Fax:703-766-2654
Is Sole Proprietor?:No
Enumeration Date:2006-04-21
Last Update Date:2009-11-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA868102207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA016037861Medicaid
VA016037861Medicaid
192965W30Medicare PIN