Healthcare Provider Details

I. General information

NPI: 1508805284
Provider Name (Legal Business Name): MICHAEL GLENN WOLFORD D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 03/19/2024
Certification Date: 03/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 WATERWAY RD
TEQUESTA FL
33469-2764
US

IV. Provider business mailing address

200 WATERWAY RD APT 104
TEQUESTA FL
33469-2752
US

V. Phone/Fax

Practice location:
  • Phone: 561-422-7334
  • Fax:
Mailing address:
  • Phone: 561-524-5871
  • Fax: 561-746-2997

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number0102201564
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberOS007470L
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberOS9197
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: