MEDICARE: DR. JONATHAN T WISEMAN DO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	25MB07242800	NJ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1063548154
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JONATHAN T WISEMAN DO

Provider Business Mailing Address
First Line	:	129 BRIDGEBORO ST
Second Line	:
City	:	RIVERSIDE
State	:	NJ
Zip	:	08075-3201
Country	:	US
Telephone Number	:	856-461-0766
Fax Number	:	856-461-7095

Provider Business Practice Location Address
First Line	:	129 BRIDGEBORO ST
Second Line	:
City	:	RIVERSIDE
State	:	NJ
Zip	:	08075-3201
Country	:	US
Telephone Number	:	856-461-0766
Fax Number	:	856-461-7095

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/26/2007
Last Update Date	:	03/02/2015

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