Healthcare Provider Details

I. General information

NPI: 1689610669
Provider Name (Legal Business Name): THOMAS WISE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

INOVA FAIRFAX HOSPITAL 3300 GALLOWS ROAD
FALLS CHURCH VA
22042-3300
US

IV. Provider business mailing address

INOVA FAIRFAX HOSPITAL 3300 GALLOWS ROAD
FALLS CHURCH VA
22042-3300
US

V. Phone/Fax

Practice location:
  • Phone: 703-776-3626
  • Fax:
Mailing address:
  • Phone: 703-776-3626
  • Fax: 703-776-3029

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberD15386
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: