Provider Demographics
NPI:1033161245
Name:WISE, STEVEN EDWARD (OD)
Entity Type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:EDWARD
Last Name:WISE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2408 JAMIE LN
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68512-9431
Mailing Address - Country:US
Mailing Address - Phone:402-435-3015
Mailing Address - Fax:
Practice Address - Street 1:1501 PINE LAKE RD
Practice Address - Street 2:SUITE #1
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68512-3692
Practice Address - Country:US
Practice Address - Phone:402-421-7773
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1123152W00000X, 152WC0802X, 152WS0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered152W00000XEye and Vision Services ProvidersOptometrist
Not Answered152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Not Answered152WS0006XEye and Vision Services ProvidersOptometristSports Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
NEU73421Medicare UPIN
NEWI273077Medicare ID - Type Unspecified