Healthcare Provider Details

I. General information

NPI: 1992125355
Provider Name (Legal Business Name): JOHNATHAN LLOYD WISE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2014
Last Update Date: 04/06/2026
Certification Date: 04/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

406 N ACADIA RD
THIBODAUX LA
70301-4856
US

IV. Provider business mailing address

506 N ACADIA RD
THIBODAUX LA
70301-4862
US

V. Phone/Fax

Practice location:
  • Phone: 985-446-2890
  • Fax: 985-446-2189
Mailing address:
  • Phone: 985-448-1121
  • Fax: 985-446-8765

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberMD.308148
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: