Healthcare Provider Details

I. General information

NPI: 1972541399
Provider Name (Legal Business Name): WISAM N OWAIS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 VETERANS DR DEPARTMENT OF VETERAN AFFAIRS MEDICAL CENTER
LEXINGTON KY
40502-2235
US

IV. Provider business mailing address

928 STAR GAZE DR
LEXINGTON KY
40509-4471
US

V. Phone/Fax

Practice location:
  • Phone: 859-233-4511
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number30142
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: