Healthcare Provider Details

I. General information

NPI: 1811930795
Provider Name (Legal Business Name): DANA WISEMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 MANSFIELD AVE
WILLIMANTIC CT
06226-2018
US

IV. Provider business mailing address

40 MANSFIELD AVE
WILLIMANTIC CT
06226-2018
US

V. Phone/Fax

Practice location:
  • Phone: 860-450-7471
  • Fax: 860-450-0213
Mailing address:
  • Phone: 860-450-7471
  • Fax: 860-450-0213

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number29768
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: