Provider Demographics
NPI:1316152069
Name:WOLFE, THERESA R (MD)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:R
Last Name:WOLFE
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:R
Other - Last Name:KENT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1221 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504-2701
Mailing Address - Country:US
Mailing Address - Phone:859-258-6200
Mailing Address - Fax:859-258-6203
Practice Address - Street 1:1207 S BROADWAY
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-2701
Practice Address - Country:US
Practice Address - Phone:859-258-4312
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2025-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY446232081P0004X, 2081P0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P0004XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSpinal Cord Injury Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100175110Medicaid
KY7100175110Medicaid