Provider Demographics
NPI:1043399900
Name:WISNIOSKI, STANLEY WALTER III (DO)
Entity Type:Individual
Prefix:DR
First Name:STANLEY
Middle Name:WALTER
Last Name:WISNIOSKI
Suffix:III
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10887 N MILITARY TRL STE 5
Mailing Address - Street 2:
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33410-6528
Mailing Address - Country:US
Mailing Address - Phone:561-324-9600
Mailing Address - Fax:561-779-9980
Practice Address - Street 1:10887 N MILITARY TRL STE 5
Practice Address - Street 2:
Practice Address - City:PALM BEACH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33410-6528
Practice Address - Country:US
Practice Address - Phone:561-324-9600
Practice Address - Fax:561-799-9980
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-03
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS9152207Q00000X, 204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL52028OtherBLUE CROSS BLUE SHIELD ID
FLK6281OtherMEDICARE GROUP ID
FLU3317ZOtherMEDICARE SIFFIX
FLOS9152OtherMEDICAL LICENSE NUMBER
FL52028OtherBLUE CROSS BLUE SHIELD ID