MEDICARE: JAMES BERRY WISE MD

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	207W00000X	Ophthalmology Physician	8282	OK
2	207W00000X	Ophthalmology Physician	AW2160024	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	8282	OTHER	OK	STATE LICENSE

General Provider Information

NPI Number	:	1386615128
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAMES BERRY WISE MD

Provider Business Mailing Address
First Line	:	3435 NW 56TH ST
Second Line	:	STE #1010 A
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73112-4442
Country	:	US
Telephone Number	:	405-945-4747
Fax Number	:	405-945-4748

Provider Business Practice Location Address
First Line	:	3435 NW 56TH ST
Second Line	:	STE #1010 A
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73112-4442
Country	:	US
Telephone Number	:	405-945-4747
Fax Number	:	405-945-4748

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

Provider Enumeration Date	:	01/30/2006
Last Update Date	:	03/07/2023

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