Healthcare Provider Details

I. General information

NPI: 1386610236
Provider Name (Legal Business Name): RICHARD G WISE D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2006
Last Update Date: 11/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 SYCAMORE DR
NEW MIDDLETOWN OH
44442-9754
US

IV. Provider business mailing address

PO BOX 272
NEW MIDDLETOWN OH
44442-0272
US

V. Phone/Fax

Practice location:
  • Phone: 330-542-2881
  • Fax: 330-542-0074
Mailing address:
  • Phone: 330-542-2881
  • Fax: 330-542-0074

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number34-003728
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: