Healthcare Provider Details

I. General information

NPI: 1790941334
Provider Name (Legal Business Name): WAYNE OLIVER WOLVERTON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: WAYNE O WOLVERTON

II. Dates (important events)

Enumeration Date: 08/04/2008
Last Update Date: 09/30/2025
Certification Date: 09/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 BRULE ST
FORT KNOX KY
40121-6100
US

IV. Provider business mailing address

5410 MARYLAND WAY STE 300
BRENTWOOD TN
37027-5339
US

V. Phone/Fax

Practice location:
  • Phone: 502-626-9789
  • Fax: 502-624-0482
Mailing address:
  • Phone: 615-377-5602
  • Fax: 615-271-1692

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License Number04033
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number04033
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: