Healthcare Provider Details

I. General information

NPI: 1801968797
Provider Name (Legal Business Name): FRED I WOLFSON L.AC.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 PARK AVE
FREDERICK MD
21701-4931
US

IV. Provider business mailing address

10217 WHITE PELICAN WAY 105C
NEW MARKET MD
21774-2908
US

V. Phone/Fax

Practice location:
  • Phone: 301-788-9451
  • Fax:
Mailing address:
  • Phone: 301-788-9451
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberU01417
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: