Provider Demographics
NPI:1053390856
Name:WOLYNIAK, JOSEPH S (DO)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:S
Last Name:WOLYNIAK
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 1:7004 SMITH CORNERS BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28269-3793
Mailing Address - Country:US
Mailing Address - Phone:704-688-9650
Mailing Address - Fax:704-688-9651
Practice Address - Street 1:7004 SMITH CORNERS BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28269-3793
Practice Address - Country:US
Practice Address - Phone:704-688-9650
Practice Address - Fax:704-688-9651
Is Sole Proprietor?:No
Enumeration Date:2006-01-11
Last Update Date:2011-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9600781208000000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8989001Medicaid
NC8989001Medicaid
370021782Medicare PIN
NCG28367Medicare UPIN