Provider Demographics
NPI:1063676443
Name:TERESA A. WISE, O.D., P.S.C.
Entity Type:Organization
Organization Name:TERESA A. WISE, O.D., P.S.C.
Other - Org Name:WISE VISION CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:WISE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:270-769-3708
Mailing Address - Street 1:2904 DOLPHIN DR
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-7102
Mailing Address - Country:US
Mailing Address - Phone:270-769-3708
Mailing Address - Fax:270-765-2043
Practice Address - Street 1:2904 DOLPHIN DR
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-7102
Practice Address - Country:US
Practice Address - Phone:270-769-3708
Practice Address - Fax:270-765-2043
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-15
Last Update Date:2008-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1156DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY770011567Medicaid
KY9341001Medicare PIN
KYT92116Medicare UPIN
KY770011567Medicaid