Provider Demographics
NPI:1457383051
Name:WOLKOV, JAY MICHAEL (DO)
Entity type:Individual
Prefix:
First Name:JAY
Middle Name:MICHAEL
Last Name:WOLKOV
Suffix:
Gender:M
Credentials:DO
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 839
Mailing Address - Street 2:
Mailing Address - City:GUNNISON
Mailing Address - State:CO
Mailing Address - Zip Code:81230-0839
Mailing Address - Country:US
Mailing Address - Phone:970-641-1771
Mailing Address - Fax:970-641-9017
Practice Address - Street 1:707 N IOWA ST
Practice Address - Street 2:
Practice Address - City:GUNNISON
Practice Address - State:CO
Practice Address - Zip Code:81230-2229
Practice Address - Country:US
Practice Address - Phone:970-641-1771
Practice Address - Fax:970-641-9017
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2010-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO18278207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01182781Medicaid
CD7108Medicare ID - Type Unspecified
CO01182781Medicaid