Provider Demographics
NPI:1235115650
Name:WISMAN, PAUL PENCE JR (MD)
Entity Type:Individual
Prefix:MR
First Name:PAUL
Middle Name:PENCE
Last Name:WISMAN
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:104 KERRY LN
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22901-2925
Mailing Address - Country:US
Mailing Address - Phone:434-973-3806
Mailing Address - Fax:
Practice Address - Street 1:1011 E JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22902-5354
Practice Address - Country:US
Practice Address - Phone:434-296-9161
Practice Address - Fax:434-296-1036
Is Sole Proprietor?:No
Enumeration Date:2005-12-17
Last Update Date:2012-09-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0101049022208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA12211500001OtherSOUTHERN HEALTH
VA010724OtherCIGNA
VA267258OtherMAMSI/ALLIANCE
VA333848OtherANTHEM
VA006725856Medicaid
VA42728OtherVETRI