Provider Demographics
NPI:1104027150
Name:WISEMAN, COLETTE H (MD)
Entity Type:Individual
Prefix:DR
First Name:COLETTE
Middle Name:H
Last Name:WISEMAN
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 1:1330 STANFORD ST APT D
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2543
Mailing Address - Country:US
Mailing Address - Phone:310-736-8999
Mailing Address - Fax:
Practice Address - Street 1:1330 STANFORD ST APT D
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2543
Practice Address - Country:US
Practice Address - Phone:310-736-8999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-29
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA106115207R00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine