Provider Demographics
NPI:1447459672
Name:ERIC R. WOLF, M.D., P.C.
Entity type:Organization
Organization Name:ERIC R. WOLF, M.D., P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:R
Authorized Official - Last Name:WOLF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-449-9090
Mailing Address - Street 1:495 GOLD STAR HWY
Mailing Address - Street 2:SUITE 108
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06340-6228
Mailing Address - Country:US
Mailing Address - Phone:860-449-9090
Mailing Address - Fax:860-445-7246
Practice Address - Street 1:495 GOLD STAR HWY
Practice Address - Street 2:SUITE 108
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06340-6228
Practice Address - Country:US
Practice Address - Phone:860-449-9090
Practice Address - Fax:860-445-7246
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-17
Last Update Date:2007-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT023620207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1236207Medicaid
CT1236207Medicaid