Provider Demographics
NPI:1043390370
Name:WISDOM MEDICAL INC
Entity Type:Organization
Organization Name:WISDOM MEDICAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:O
Authorized Official - Last Name:ONWA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:720-748-1014
Mailing Address - Street 1:PO BOX 202913
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80220-8913
Mailing Address - Country:US
Mailing Address - Phone:720-748-1014
Mailing Address - Fax:720-748-1014
Practice Address - Street 1:2620 S PARKER RD
Practice Address - Street 2:SUITE #160
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80014-1608
Practice Address - Country:US
Practice Address - Phone:720-748-1014
Practice Address - Fax:720-748-1014
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2009-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO7247331332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO66622247Medicaid
CO5858940001Medicare NSC