Provider Demographics
NPI:1861576415
Name:WOLF, MARK J (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:J
Last Name:WOLF
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:103 E 23RD ST
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-4501
Mailing Address - Country:US
Mailing Address - Phone:850-769-0338
Mailing Address - Fax:850-785-6088
Practice Address - Street 1:103 E 23RD ST
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-4501
Practice Address - Country:US
Practice Address - Phone:850-769-0338
Practice Address - Fax:850-785-6088
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2011-07-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME21062207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL065956800Medicaid
D58445Medicare UPIN