Healthcare Provider Details

I. General information

NPI: 1417913104
Provider Name (Legal Business Name): JONATHAN PAUL WULFF DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/22/2006
Last Update Date: 03/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 KYLE STREET
EATON RAPIDS MI
48827
US

IV. Provider business mailing address

PO BOX 269
EATON RAPIDS MI
48827
US

V. Phone/Fax

Practice location:
  • Phone: 517-663-4821
  • Fax: 517-663-5650
Mailing address:
  • Phone: 517-663-4821
  • Fax: 517-663-5650

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberJW006732
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: