Healthcare Provider Details

I. General information

NPI: 1679215560
Provider Name (Legal Business Name): BENJAMIN ANTHONY WISE DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2022
Last Update Date: 07/31/2026
Certification Date: 07/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2803 MEDICAL CAMPUS DR
GOLDSBORO NC
27531-2301
US

IV. Provider business mailing address

2803 MEDICAL CAMPUS DR
GOLDSBORO NC
27531-2301
US

V. Phone/Fax

Practice location:
  • Phone: 919-722-0957
  • Fax:
Mailing address:
  • Phone: 919-722-0957
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number34.017530
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number2884
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: