Healthcare Provider Details

I. General information

NPI: 1720246614
Provider Name (Legal Business Name): MELISSA JO WISE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2008
Last Update Date: 03/17/2021
Certification Date: 02/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

159 S ENGLISH STATION RD
LOUISVILLE KY
40245-3996
US

IV. Provider business mailing address

801 YORK ST
MANITOWOC WI
54220-4630
US

V. Phone/Fax

Practice location:
  • Phone: 502-753-0056
  • Fax: 502-756-0626
Mailing address:
  • Phone: 920-663-9146
  • Fax: 920-684-1439

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberMT190084
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number43415
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: