MEDICARE: DENISE KATHLEEN WISE M.D.

Medicare Provider Information

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0202X	Diagnostic Radiology Physician	A74394	CA
2	2085R0202X	Diagnostic Radiology Physician	K3002	TX

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

NPI Number	:	1184634586
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DENISE KATHLEEN WISE M.D.

Provider Business Mailing Address
First Line	:	800 5TH AVE
Second Line	:	SUITE 400
City	:	FORT WORTH
State	:	TX
Zip	:	76104-7300
Country	:	US
Telephone Number	:	817-924-1999
Fax Number	:	817-886-0881

Provider Business Practice Location Address
First Line	:	800 5TH AVE
Second Line	:	SUITE 400
City	:	FORT WORTH
State	:	TX
Zip	:	76104-7300
Country	:	US
Telephone Number	:	817-924-1999
Fax Number	:	817-886-0881

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

Provider Enumeration Date	:	08/08/2006
Last Update Date	:	02/11/2015

800 5TH AVE , SUITE 150
FORT WORTH, TX
76104-7300

Practice Phone: 817-810-7504
Practice Fax: 817-810-7501

800 5TH AVE , SUITE 300
FORT WORTH, TX
76104-7300