Provider Demographics
NPI:1023394970
Name:WISEMAN, JAMIE R (MD)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:R
Last Name:WISEMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JAMIE
Other - Middle Name:R
Other - Last Name:HITCHLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:10012 N CREEK RD
Mailing Address - Street 2:
Mailing Address - City:COMFORT
Mailing Address - State:TX
Mailing Address - Zip Code:78013-3700
Mailing Address - Country:US
Mailing Address - Phone:210-326-6098
Mailing Address - Fax:
Practice Address - Street 1:10012 N CREEK RD
Practice Address - Street 2:
Practice Address - City:COMFORT
Practice Address - State:TX
Practice Address - Zip Code:78013-3700
Practice Address - Country:US
Practice Address - Phone:210-326-6098
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-24
Last Update Date:2019-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK8301207Q00000X
WI57425-20207Q00000X, 390200000X
WI3956-850390200000X
TXQ1331207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1023394970OtherBCBCWI
WI1023394970Medicaid
IL158697344 1Medicaid
AK1622061Medicaid
WIHITCHJAMOtherMERCYCARE INSURANCE
WI541760917Medicare PIN