Healthcare Provider Details

I. General information

NPI: 1902246820
Provider Name (Legal Business Name): MATTHEW JOHN WOLF M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2013
Last Update Date: 04/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 S HEATON ST
MORRISON IL
61270
US

IV. Provider business mailing address

1345 W CENTRAL PARK AVE
DAVENPORT IA
52804-1844
US

V. Phone/Fax

Practice location:
  • Phone: 815-625-4790
  • Fax:
Mailing address:
  • Phone: 563-421-4400
  • Fax: 563-421-4449

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036140324
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: