Provider Demographics
NPI:1972562148
Name:WULFF, DAVID M
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:M
Last Name:WULFF
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1941 VIRGINIA AVE
Mailing Address - Street 2:
Mailing Address - City:CONNERSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47331-2833
Mailing Address - Country:US
Mailing Address - Phone:765-827-7762
Mailing Address - Fax:765-827-7796
Practice Address - Street 1:3542 WESTERN AVE
Practice Address - Street 2:
Practice Address - City:CONNERSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47331-3427
Practice Address - Country:US
Practice Address - Phone:765-825-5323
Practice Address - Fax:765-825-8274
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2008-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10000305A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN$$$$$$$$$OtherTRICARE
IN$$$$$$$$$OtherTRICARE
IN183460FMedicare PIN