Healthcare Provider Details

I. General information

NPI: 1508862509
Provider Name (Legal Business Name): PHILIP WISOTSKY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2005
Last Update Date: 11/19/2021
Certification Date: 11/19/2021
Deactivation Date: 03/16/2006
Reactivation Date: 03/31/2006

III. Provider practice location address

11350 PEMBROOKE SQ STE 311
WALDORF MD
20603-4809
US

IV. Provider business mailing address

11350 PEMBROOKE SQ STE 311
WALDORF MD
20603-4809
US

V. Phone/Fax

Practice location:
  • Phone: 301-870-0660
  • Fax: 301-932-8310
Mailing address:
  • Phone: 301-870-0660
  • Fax: 301-932-8310

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberD18545
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License NumberD18545
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: