MEDICARE: KENNETH R. WULFF MD

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	2084P0804X	Child & Adolescent Psychiatry Physician	G32683	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1124105085
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENNETH R. WULFF MD

Provider Business Mailing Address
First Line	:	1503 SPRING HILL RD
Second Line	:
City	:	PETALUMA
State	:	CA
Zip	:	94952-9305
Country	:	US
Telephone Number	:	707-559-3895
Fax Number	:

Provider Business Practice Location Address
First Line	:	1503 SPRING HILL RD
Second Line	:
City	:	PETALUMA
State	:	CA
Zip	:	94952-9305
Country	:	US
Telephone Number	:	707-559-3895
Fax Number	:

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

Provider Enumeration Date	:	10/31/2006
Last Update Date	:	01/18/2024

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