Provider Demographics
NPI:1679668123
Name:WOLFE, RICHARD JOHN (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:JOHN
Last Name:WOLFE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1550 BISHOP CT
Mailing Address - Street 2:
Mailing Address - City:MOUNT PROSPECT
Mailing Address - State:IL
Mailing Address - Zip Code:60056-6039
Mailing Address - Country:US
Mailing Address - Phone:847-685-9900
Mailing Address - Fax:
Practice Address - Street 1:1550 BISHOP CT
Practice Address - Street 2:
Practice Address - City:MOUNT PROSPECT
Practice Address - State:IL
Practice Address - Zip Code:60056-6039
Practice Address - Country:US
Practice Address - Phone:847-685-9900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-105593207QG0300X
IL036105593207QH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-105593Medicaid
IL036-105593Medicaid