Provider Demographics
NPI:1902061849
Name:WOLF, NICHOLAS LEROY (OD)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:LEROY
Last Name:WOLF
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11559 CUMBERLAND RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46037-9784
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10232 WESTPORT RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40241-2148
Practice Address - Country:US
Practice Address - Phone:502-339-2042
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-21
Last Update Date:2012-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003526152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1879DTOtherKENTUCKY OPTOMETRY LICENSE
IN18003526A/BOtherINDIANA OPTOMETRY LICENSE