Provider Demographics
NPI:1316262280
Name:WOLFE, JOSHUA P (MD)
Entity type:Individual
Prefix:DR
First Name:JOSHUA
Middle Name:P
Last Name:WOLFE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 47
Mailing Address - Street 2:
Mailing Address - City:LICKING
Mailing Address - State:MO
Mailing Address - Zip Code:65542-0047
Mailing Address - Country:US
Mailing Address - Phone:573-674-3011
Mailing Address - Fax:573-674-4765
Practice Address - Street 1:233 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LICKING
Practice Address - State:MO
Practice Address - Zip Code:65542-0047
Practice Address - Country:US
Practice Address - Phone:573-674-3011
Practice Address - Fax:573-674-4765
Is Sole Proprietor?:No
Enumeration Date:2010-04-02
Last Update Date:2013-08-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2013029561207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1316262280Medicaid
MO26D0679044OtherCLIA
MO268630Medicare Oscar/Certification