Healthcare Provider Details

I. General information

NPI: 1366419434
Provider Name (Legal Business Name): BARRY R WISS D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2006
Last Update Date: 05/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5823 W EUGIE AVE STE A
GLENDALE AZ
85304-1276
US

IV. Provider business mailing address

3707 N 7TH ST #305
PHOENIX AZ
85014-5059
US

V. Phone/Fax

Practice location:
  • Phone: 602-843-1265
  • Fax: 602-843-1297
Mailing address:
  • Phone: 602-264-9100
  • Fax: 602-264-9101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number2029
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: