Basic Information
| Provider Information | |||||||||
| NPI: | 1457383051 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WOLKOV | ||||||||
| FirstName: | JAY | ||||||||
| MiddleName: | MICHAEL | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 839 | ||||||||
| Address2: | |||||||||
| City: | GUNNISON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 812300839 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9706411771 | ||||||||
| FaxNumber: | 9706419017 | ||||||||
| Practice Location | |||||||||
| Address1: | 707 N IOWA ST | ||||||||
| Address2: | |||||||||
| City: | GUNNISON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 812302229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9706411771 | ||||||||
| FaxNumber: | 9706419017 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2006 | ||||||||
| LastUpdateDate: | 02/09/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 18278 | CO | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 01182781 | 05 | CO | MEDICAID |