Healthcare Provider Details

I. General information

NPI: 1053314666
Provider Name (Legal Business Name): DANIEL H WISSINGER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1203 RIDGEWAY RD STE 201
MEMPHIS TN
38119-5316
US

IV. Provider business mailing address

1203 RIDGEWAY RD STE 201
MEMPHIS TN
38119-5316
US

V. Phone/Fax

Practice location:
  • Phone: 901-761-5544
  • Fax: 901-761-9088
Mailing address:
  • Phone: 901-761-5544
  • Fax: 901-761-9088

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberMD20384
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: