Provider Demographics
NPI:1962024067
Name:WOLF, BARRY (MD)
Entity type:Individual
Prefix:
First Name:BARRY
Middle Name:
Last Name:WOLF
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:247 S OCEAN BLVD UNIT B
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33432-6439
Mailing Address - Country:US
Mailing Address - Phone:561-951-9225
Mailing Address - Fax:
Practice Address - Street 1:JACKWOLF LLC
Practice Address - Street 2:247 S. OCEAN BLVD
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33432
Practice Address - Country:US
Practice Address - Phone:561-961-9225
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-12
Last Update Date:2020-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL646878OtherPHYSICIAN DIRECT