Healthcare Provider Details

I. General information

NPI: 1407488182
Provider Name (Legal Business Name): TOM WULF MD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2020
Last Update Date: 05/11/2020
Certification Date: 05/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

607 W COUNTRY CLUB RD
ROSWELL NM
88201-5211
US

IV. Provider business mailing address

313 W COUNTRY CLUB RD STE 15
ROSWELL NM
88201-5804
US

V. Phone/Fax

Practice location:
  • Phone: 575-208-7795
  • Fax: 575-208-7785
Mailing address:
  • Phone: 575-208-7795
  • Fax: 575-208-7785

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251G00000X
TaxonomyCommunity Based Hospice Care Agency
License Number
License Number State

VIII. Authorized Official

Name: THOMAS WULF
Title or Position: OWNER
Credential: MD
Phone: 575-208-7795