MEDICARE: JOHNATHAN LLOYD WISE MD

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	207V00000X	Obstetrics & Gynecology Physician	MD.308148	LA

General Provider Information

NPI Number	:	1992125355
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHNATHAN LLOYD WISE MD

Provider Business Mailing Address
First Line	:	506 N ACADIA RD
Second Line	:
City	:	THIBODAUX
State	:	LA
Zip	:	70301-4862
Country	:	US
Telephone Number	:	985-448-1121
Fax Number	:	985-446-8765

Provider Business Practice Location Address
First Line	:	406 N ACADIA RD
Second Line	:
City	:	THIBODAUX
State	:	LA
Zip	:	70301-4856
Country	:	US
Telephone Number	:	985-446-2890
Fax Number	:	985-446-2189

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

Provider Enumeration Date	:	04/23/2014
Last Update Date	:	04/06/2026

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