Provider Demographics
NPI:1871587550
Name:WOLFGANG, ROBERT (DO)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:WOLFGANG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1150 RESERVOIR AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02920-6068
Mailing Address - Country:US
Mailing Address - Phone:401-943-1300
Mailing Address - Fax:401-946-8480
Practice Address - Street 1:1150 RESERVOIR AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:CRANSTON
Practice Address - State:RI
Practice Address - Zip Code:02920-6068
Practice Address - Country:US
Practice Address - Phone:401-943-1300
Practice Address - Fax:401-946-8480
Is Sole Proprietor?:No
Enumeration Date:2005-09-08
Last Update Date:2010-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIRI501207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIIM02288Medicaid
RI007007284Medicare ID - Type Unspecified
RIIM02288Medicaid