Provider Demographics
NPI:1164521589
Name:WISE, GARETT (OD)
Entity Type:Individual
Prefix:DR
First Name:GARETT
Middle Name:
Last Name:WISE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1406 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29526-3567
Mailing Address - Country:US
Mailing Address - Phone:843-488-2020
Mailing Address - Fax:843-488-0141
Practice Address - Street 1:1406 MAIN ST
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526-3567
Practice Address - Country:US
Practice Address - Phone:843-488-2020
Practice Address - Fax:843-488-0141
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1438152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCD14385Medicaid
SCV10698Medicare UPIN
SCP00434569Medicare PIN