Healthcare Provider Details

I. General information

NPI: 1821283912
Provider Name (Legal Business Name): DR. SHOUKRI M. WISA MEDICAL CARE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2007
Last Update Date: 04/03/2014
Certification Date:
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 Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. SHOUKRI MINA WISA
Title or Position: OWNER
Credential: M.D.
Phone: 585-343-6363