Provider Demographics
NPI:1043206261
Name:WOLF, SUSAN D (MD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:D
Last Name:WOLF
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:136 N SAN MATEO DR
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94401-2777
Mailing Address - Country:US
Mailing Address - Phone:650-348-1242
Mailing Address - Fax:650-348-0788
Practice Address - Street 1:136 N SAN MATEO DR FL 2
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94401-2778
Practice Address - Country:US
Practice Address - Phone:650-348-1242
Practice Address - Fax:650-348-0788
Is Sole Proprietor?:No
Enumeration Date:2005-09-22
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA66326207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
H34667Medicare UPIN
CAH34667Medicare UPIN
CA00A663260Medicare ID - Type Unspecified