Provider Demographics
NPI:1164403051
Name:WISE, ROBERT HAROLD JR (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:HAROLD
Last Name:WISE
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 3670
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31604-3670
Mailing Address - Country:US
Mailing Address - Phone:229-333-9729
Mailing Address - Fax:
Practice Address - Street 1:2704 N OAK ST
Practice Address - Street 2:BUILDING E
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-1744
Practice Address - Country:US
Practice Address - Phone:229-333-9729
Practice Address - Fax:229-333-0832
Is Sole Proprietor?:No
Enumeration Date:2005-11-08
Last Update Date:2011-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0266872085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000322022AMedicaid
GAE28006Medicare UPIN
GA000322022AMedicaid
GA300020860Medicare PIN