MEDICARE: SHIRA WOLFSON RD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian
2	133V00000X	Registered Dietitian	009838	NY

General Provider Information

NPI Number	:	1003388315
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHIRA WOLFSON RD

Provider Business Mailing Address
First Line	:	1487 E TERRACE CIR APT 6
Second Line	:
City	:	TEANECK
State	:	NJ
Zip	:	07666-5220
Country	:	US
Telephone Number	:	347-346-1449
Fax Number	:

Provider Business Practice Location Address
First Line	:	522 E 9TH ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11218-5221
Country	:	US
Telephone Number	:	718-435-5009
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/27/2018
Last Update Date	:	04/21/2021

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