Healthcare Provider Details

I. General information

NPI: 1235107038
Provider Name (Legal Business Name): MATTHEW JAY WISE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2006
Last Update Date: 03/04/2024
Certification Date: 03/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

431 S BATAVIA ST STE 101
ORANGE CA
92868-3937
US

IV. Provider business mailing address

431 S BATAVIA ST STE 101
ORANGE CA
92868-3937
US

V. Phone/Fax

Practice location:
  • Phone: 714-363-3300
  • Fax: 714-363-3847
Mailing address:
  • Phone: 714-363-3300
  • Fax: 714-363-3847

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code202K00000X
TaxonomyPhlebology Physician
License NumberC55031
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: