Healthcare Provider Details

I. General information

NPI: 1164545166
Provider Name (Legal Business Name): OLIVER JAYME WISCO D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2007
Last Update Date: 12/19/2025
Certification Date: 12/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

DERMATOLOGY HEALTH SPCECIALIST 1693 SW CHANDLER AVE SUITE 250
BEND OR
97702-3231
US

IV. Provider business mailing address

15 LA SALLE SQ
PROVIDENCE RI
02903-1814
US

V. Phone/Fax

Practice location:
  • Phone: 541-382-8819
  • Fax:
Mailing address:
  • Phone: 401-444-6779
  • Fax: 401-444-6912

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberDO157812
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberDO01032
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: