Healthcare Provider Details

I. General information

NPI: 1306895370
Provider Name (Legal Business Name): SHOUKRI MINA WISA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2006
Last Update Date: 04/28/2021
Certification Date: 04/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

164 WASHINGTON AVE
BATAVIA NY
14020-2113
US

IV. Provider business mailing address

164 WASHINGTON AVE
BATAVIA NY
14020-2113
US

V. Phone/Fax

Practice location:
  • Phone: 585-343-6363
  • Fax: 585-343-1986
Mailing address:
  • Phone: 585-343-6363
  • Fax: 585-343-1986

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number1705271
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number170527
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: