Healthcare Provider Details

I. General information

NPI: 1336438258
Provider Name (Legal Business Name): DAVID R WISE M.D., PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2011
Last Update Date: 11/06/2020
Certification Date: 11/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 E 34TH ST
NEW YORK NY
10016-4744
US

IV. Provider business mailing address

PO BOX 148 505 EAST 70TH STREET
NEW YORK NY
10021-0012
US

V. Phone/Fax

Practice location:
  • Phone: 212-731-6366
  • Fax: 212-731-5527
Mailing address:
  • Phone: 212-746-3587
  • Fax: 212-746-8051

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number270704
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: