Healthcare Provider Details

I. General information

NPI: 1124084405
Provider Name (Legal Business Name): DAVID WISOTSKY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2006
Last Update Date: 07/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32 FRANKLIN ST TENAFLY PEDIATRICS
TENAFLY NJ
07670-2005
US

IV. Provider business mailing address

32 FRANKLIN ST TENAFLY PEDIATRICS
TENAFLY NJ
07670-2005
US

V. Phone/Fax

Practice location:
  • Phone: 201-569-2400
  • Fax: 201-816-0136
Mailing address:
  • Phone: 201-569-2400
  • Fax: 201-816-0136

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number25MA03472400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: