Healthcare Provider Details

I. General information

NPI: 1669674081
Provider Name (Legal Business Name): BRYAN JACOB WOHLFELD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2007
Last Update Date: 08/19/2020
Certification Date: 08/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

719 W 2ND ST
BLOOMINGTON IN
47403-2209
US

IV. Provider business mailing address

PO BOX 845347
DALLAS TX
75284-5347
US

V. Phone/Fax

Practice location:
  • Phone: 812-676-4730
  • Fax: 812-676-4731
Mailing address:
  • Phone: 214-645-2300
  • Fax: 214-645-2301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number01084250A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License NumberN7764
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: