MEDICARE: JONATHAN T WISEMAN DO PA

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

General Provider Information

NPI Number	:	1568597086
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JONATHAN T WISEMAN DO PA

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	:	215-523-9281

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	:	215-523-9281

Authorized Official
Title or Position	:	PHYSICIAN
Name	:	JONATHAN WISEMAN
Credential	:	DO
Telephone Number	:	856-761-0766

Provider Enumeration Date	:	02/23/2007
Last Update Date	:	01/07/2011

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