Provider Demographics
NPI:1750432308
Name:WOLF, ROBERT
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:
Last Name:WOLF
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 N MADISON ST
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:IL
Mailing Address - Zip Code:60098-3450
Mailing Address - Country:US
Mailing Address - Phone:815-338-7810
Mailing Address - Fax:
Practice Address - Street 1:206 N MADISON ST
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:IL
Practice Address - Zip Code:60098-3450
Practice Address - Country:US
Practice Address - Phone:815-338-7810
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-12
Last Update Date:2008-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0046008431152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0046008431Medicaid
ILU57649Medicare UPIN
IL0046008431Medicaid