Provider Demographics
NPI:1184634586
Name:WISE, DENISE KATHLEEN (MD)
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:KATHLEEN
Last Name:WISE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DENISE
Other - Middle Name:KATHLEEN
Other - Last Name:SCHROEDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:800 5TH AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-7300
Mailing Address - Country:US
Mailing Address - Phone:817-924-1999
Mailing Address - Fax:817-886-0881
Practice Address - Street 1:800 5TH AVE
Practice Address - Street 2:SUITE 400
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-7300
Practice Address - Country:US
Practice Address - Phone:817-924-1999
Practice Address - Fax:817-886-0881
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2015-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA743942085R0202X
TXK30022085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A743940Medicaid
TX104612003Medicaid
TX104612005Medicaid
G77896Medicare UPIN
TX8J7056Medicare PIN
00A743940Medicare ID - Type Unspecified
TX104612003Medicaid
CA00A743940Medicaid