Healthcare Provider Details

I. General information

NPI: 1710931738
Provider Name (Legal Business Name): DOUGLAS C WISCH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2006
Last Update Date: 06/17/2021
Certification Date: 06/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

245 ALVORD PARK RD
TORRINGTON CT
06790
US

IV. Provider business mailing address

245 ALVORD PARK RD
TORRINGTON CT
06790
US

V. Phone/Fax

Practice location:
  • Phone: 860-482-8539
  • Fax: 860-482-0258
Mailing address:
  • Phone: 860-482-8539
  • Fax: 860-482-0258

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number032872
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code207XS0106X
TaxonomyOrthopaedic Hand Surgery Physician
License Number032872
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code2086S0105X
TaxonomySurgery of the Hand (Surgery) Physician
License Number032872
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: