Provider Demographics
NPI:1235133760
Name:WISEMAN, C. VINCE (MD)
Entity Type:Individual
Prefix:DR
First Name:C.
Middle Name:VINCE
Last Name:WISEMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12554 RIATA VISTA CIR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78727-6431
Mailing Address - Country:US
Mailing Address - Phone:512-519-3462
Mailing Address - Fax:512-795-5122
Practice Address - Street 1:12554 RIATA VISTA CIR
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78727-6431
Practice Address - Country:US
Practice Address - Phone:512-519-3462
Practice Address - Fax:512-795-5122
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2015-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH17372085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX139262313Medicaid
300034057OtherRRMCARE
TX139262312OtherCSHCN2
TX139262306Medicaid
300127205OtherRRMCARE2
TX139262305OtherCSHCN1
TX83797RMedicare PIN
300034057OtherRRMCARE
300127205OtherRRMCARE2