Healthcare Provider Details

I. General information

NPI: 1841358587
Provider Name (Legal Business Name): IVAN S. WOLFSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 04/26/2021
Certification Date: 04/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

375 ALLENS AVE
PROVIDENCE RI
02905-5010
US

IV. Provider business mailing address

375 ALLENS AVE
PROVIDENCE RI
02905-5010
US

V. Phone/Fax

Practice location:
  • Phone: 401-444-0400
  • Fax: 401-444-0468
Mailing address:
  • Phone: 401-444-0400
  • Fax: 401-444-0468

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD8535
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License NumberMD8535
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: