MEDICARE: DR. RODNEY MARVIN WISEMAN D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	F4702	TX

General Provider Information

NPI Number	:	1508832999
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RODNEY MARVIN WISEMAN D.O.

Provider Business Mailing Address
First Line	:	PO BOX 1045
Second Line	:
City	:	WHITEHOUSE
State	:	TX
Zip	:	75791-1045
Country	:	US
Telephone Number	:	903-839-4396
Fax Number	:	903-839-8705

Provider Business Practice Location Address
First Line	:	#400 HWY 110 N
Second Line	:
City	:	WHITEHOUSE
State	:	TX
Zip	:	75791-1045
Country	:	US
Telephone Number	:	903-839-4396
Fax Number	:	903-839-8705

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/24/2006
Last Update Date	:	07/09/2007

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