Healthcare Provider Details

I. General information

NPI: 1871471490
Provider Name (Legal Business Name): COLETTE WISEMAN, MD, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2025
Last Update Date: 08/22/2025
Certification Date: 08/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

744 N KENTER AVE
LOS ANGELES CA
90049-5105
US

IV. Provider business mailing address

11693 SAN VICENTE BLVD # 445
LOS ANGELES CA
90049-5105
US

V. Phone/Fax

Practice location:
  • Phone: 424-234-6461
  • Fax:
Mailing address:
  • Phone: 424-234-6461
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. COLETTE WISEMAN
Title or Position: PRESIDENT
Credential: MD
Phone: 424-234-6461