Healthcare Provider Details

I. General information

NPI: 1154424596
Provider Name (Legal Business Name): RICHARD MARK WOLFF MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2006
Last Update Date: 07/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 BRESEE ST
DONALSONVILLE GA
39845
US

IV. Provider business mailing address

205 BRESEE ST
DONALSONVILLE GA
39845
US

V. Phone/Fax

Practice location:
  • Phone: 229-524-1307
  • Fax: 229-524-6268
Mailing address:
  • Phone: 229-524-1307
  • Fax: 229-524-6268

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME36950
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: