Provider Demographics
NPI:1396173092
Name:SEAN F. WOLFORT
Entity type:Organization
Organization Name:SEAN F. WOLFORT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SEAN
Authorized Official - Middle Name:F
Authorized Official - Last Name:WOLFORT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-242-6363
Mailing Address - Street 1:421 CHURCH ST NE
Mailing Address - Street 2:SUITE H
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22180
Mailing Address - Country:US
Mailing Address - Phone:703-242-6363
Mailing Address - Fax:
Practice Address - Street 1:421 CHURCH ST NE
Practice Address - Street 2:SUITE H
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22180-4708
Practice Address - Country:US
Practice Address - Phone:703-242-6363
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-16
Last Update Date:2013-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101238737208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA228805Medicare PIN