MEDICARE: JARED WISHIK M.D.

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	207N00000X	Dermatology Physician	125069551	IL
2	207N00000X	Dermatology Physician	M144461	FL

General Provider Information

NPI Number	:	1922460161
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JARED WISHIK M.D.

Provider Business Mailing Address
First Line	:	4651 VAN DYKE RD
Second Line	:
City	:	LUTZ
State	:	FL
Zip	:	33558-4880
Country	:	US
Telephone Number	:	813-321-1786
Fax Number	:	813-321-1787

Provider Business Practice Location Address
First Line	:	5200 SEMINOLE BLVD
Second Line	:
City	:	ST PETERSBURG
State	:	FL
Zip	:	33708-3356
Country	:	US
Telephone Number	:	813-321-1786
Fax Number	:	813-321-1787

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

Provider Enumeration Date	:	03/27/2016
Last Update Date	:	07/21/2022

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