Healthcare Provider Details

I. General information

NPI: 1760740997
Provider Name (Legal Business Name): KELLY WOLF & HERMAN M D P A
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2012
Last Update Date: 04/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8940 N KENDALL DR STE 903E
MIAMI FL
33176-2176
US

IV. Provider business mailing address

8940 N KENDALL DR STE 903E
MIAMI FL
33176-2176
US

V. Phone/Fax

Practice location:
  • Phone: 305-595-2969
  • Fax: 305-595-6491
Mailing address:
  • Phone: 305-595-2969
  • Fax: 305-595-6491

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number52283
License Number StateFL

VIII. Authorized Official

Name: CARLOS WOLF
Title or Position: DIRECTOR
Credential: M.D.
Phone: 305-595-2969