Provider Demographics
NPI:1255331310
Name:WISDOM, JILL C (DPM)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:C
Last Name:WISDOM
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:JILL
Other - Middle Name:C
Other - Last Name:KRANZOW
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DPM
Mailing Address - Street 1:6309 PRESTON RD
Mailing Address - Street 2:SUITE 1200
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75024-2606
Mailing Address - Country:US
Mailing Address - Phone:972-769-7280
Mailing Address - Fax:972-769-7287
Practice Address - Street 1:6309 PRESTON RD
Practice Address - Street 2:STE 1200
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75024-2606
Practice Address - Country:US
Practice Address - Phone:972-769-7280
Practice Address - Fax:972-769-7287
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2014-08-29
Deactivation Date:2006-03-22
Deactivation Code:
Reactivation Date:2006-03-28
Provider Licenses
StateLicense IDTaxonomies
TX1283213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8374B0Medicare PIN