Healthcare Provider Details

I. General information

NPI: 1467458000
Provider Name (Legal Business Name): JACK M WOLFSON D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2005
Last Update Date: 07/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10585 N TATUM BLVD STE D135
PARADISE VALLEY AZ
85253-1073
US

IV. Provider business mailing address

10585 N TATUM BLVD STE D135
PARADISE VALLEY AZ
85253-1073
US

V. Phone/Fax

Practice location:
  • Phone: 480-535-6844
  • Fax: 480-535-6845
Mailing address:
  • Phone: 480-535-6844
  • Fax: 480-535-6845

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number3761
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: