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General NPI Number Information
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NPI Number | 1588629794
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Entity Type | Individual
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Provider Name | JONATHAN F WISE MD
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Gender | Male
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Dates
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Enumeration Date | 04/19/2006
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Last Update Date | 07/09/2007
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Provider Practice Location Address
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Address Line | 3816 HOLLYWOOD BLVD SUITE 101
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City | HOLLYWOOD
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State | FL
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Zip | 33021-6750
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Country | US
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Telephone | 954-963-4990
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Fax | 954-963-1848
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Provider Business Mailing Address
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Address Line | 3816 HOLLYWOOD BLVD SUITE 101
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City | HOLLYWOOD
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State | FL
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Zip | 33021-6750
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Country | US
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Telephone | 954-963-4990
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Fax | 954-963-1848
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | MEOO34543
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License Number State |
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