Provider Demographics
NPI:1033128053
Name:WISNIEW, JEROME ANTHONY (DPM)
Entity Type:Individual
Prefix:DR
First Name:JEROME
Middle Name:ANTHONY
Last Name:WISNIEW
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2705 28TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92104-4902
Mailing Address - Country:US
Mailing Address - Phone:619-232-0179
Mailing Address - Fax:
Practice Address - Street 1:2306 6TH AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-1643
Practice Address - Country:US
Practice Address - Phone:619-232-0179
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE1630213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E16300Medicaid
CAT19127Medicare UPIN
CA000E16300Medicaid