Healthcare Provider Details

I. General information

NPI: 1376085282
Provider Name (Legal Business Name): DR DAVID S WISE PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2016
Last Update Date: 11/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11606 MILL ROCK RD
SAN ANTONIO TX
78230-2762
US

IV. Provider business mailing address

PO BOX 460625
SAN ANTONIO TX
78246-0625
US

V. Phone/Fax

Practice location:
  • Phone: 210-258-5009
  • Fax:
Mailing address:
  • Phone: 210-258-5009
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305S00000X
TaxonomyPoint of Service
License NumberH8963
License Number StateTX

VIII. Authorized Official

Name: DR. DAVID S WISE
Title or Position: PRESIDENT
Credential: M.D.
Phone: 210-258-5009