Provider Demographics
NPI:1093759755
Name:WISS, JOAN M (MD)
Entity Type:Individual
Prefix:DR
First Name:JOAN
Middle Name:M
Last Name:WISS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:917 MEDICAL CIRCLE
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29572
Mailing Address - Country:US
Mailing Address - Phone:843-449-0453
Mailing Address - Fax:843-282-1910
Practice Address - Street 1:917 MEDICAL CIRCLE
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29572
Practice Address - Country:US
Practice Address - Phone:843-449-0453
Practice Address - Fax:843-282-1910
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC18560207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC185604Medicaid
SC185604Medicaid