Healthcare Provider Details

I. General information

NPI: 1346543345
Provider Name (Legal Business Name): JOHN D WISE III
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/13/2010
Last Update Date: 01/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 E NORTHSIDE DR SUITE D
CLINTON MS
39056-3437
US

IV. Provider business mailing address

600 E NORTHSIDE DR SUITE D
CLINTON MS
39056-3437
US

V. Phone/Fax

Practice location:
  • Phone: 601-925-9473
  • Fax: 601-925-9490
Mailing address:
  • Phone: 601-925-9473
  • Fax: 601-925-9490

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number5337740001
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: