Healthcare Provider Details

I. General information

NPI: 1467405779
Provider Name (Legal Business Name): THOMAS W WULF M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 06/23/2020
Certification Date: 06/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

607 W COUNTRY CLUB RD
ROSWELL NM
88201-5211
US

IV. Provider business mailing address

607 W COUNTRY CLUB RD
ROSWELL NM
88201-5211
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 NumberMD2005-0529
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code207LH0002X
TaxonomyHospice and Palliative Medicine (Anesthesiology) Physician
License NumberMD2005-0529
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: