Provider Demographics
NPI:1538363494
Name:WOLF, DAWN MICHELLE (OD)
Entity type:Individual
Prefix:DR
First Name:DAWN
Middle Name:MICHELLE
Last Name:WOLF
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12813 BERESFORD DR
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48313-4113
Mailing Address - Country:US
Mailing Address - Phone:586-254-0421
Mailing Address - Fax:
Practice Address - Street 1:12813 BERESFORD DR
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48313-4113
Practice Address - Country:US
Practice Address - Phone:586-254-0421
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-13
Last Update Date:2011-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003859152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI90-0-E0-6652-0OtherBCBS PROVIDER NUMBER
MIMI2084OtherPTAN