MEDICARE: MS. DIANA LEE WOLFE M.D.

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	207R00000X	Internal Medicine Physician	2002019572	MO
2	207R00000X	Internal Medicine Physician	04-30347	KS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	611348	OTHER	MO	ANTHEM
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1477546539
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. DIANA LEE WOLFE M.D.

Provider Business Mailing Address
First Line	:	PO BOX 4046
Second Line	:
City	:	SPRINGFIELD
State	:	MO
Zip	:	65808-4046
Country	:	US
Telephone Number	:	417-269-7728
Fax Number	:	417-269-7729

Provider Business Practice Location Address
First Line	:	3801 S NATIONAL AVE
Second Line	:	5TH FLOOR
City	:	SPRINGFIELD
State	:	MO
Zip	:	65807-5210
Country	:	US
Telephone Number	:	417-269-7728
Fax Number	:	417-269-7729

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

Provider Enumeration Date	:	08/24/2005
Last Update Date	:	12/17/2012

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