Healthcare Provider Details

I. General information

NPI: 1669319562
Provider Name (Legal Business Name): JULIAN WISE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2026
Last Update Date: 04/30/2026
Certification Date: 04/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

170 MORTON ST
JAMAICA PLAIN MA
02130-3735
US

IV. Provider business mailing address

15 CURLEW ST
WEST ROXBURY MA
02132-4101
US

V. Phone/Fax

Practice location:
  • Phone: 617-522-8110
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number3021434
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: