Provider Demographics
NPI:1265475826
Name:WISMAN, RICHARD C (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:C
Last Name:WISMAN
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 1:502 MAIN ST W
Mailing Address - Street 2:
Mailing Address - City:OAK HILL
Mailing Address - State:WV
Mailing Address - Zip Code:25901-3416
Mailing Address - Country:US
Mailing Address - Phone:304-465-1030
Mailing Address - Fax:304-469-9811
Practice Address - Street 1:379 STANAFORD RD
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-3141
Practice Address - Country:US
Practice Address - Phone:304-253-3000
Practice Address - Fax:304-469-9811
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV12767207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0049654000Medicaid
WVWI0510901Medicare PIN
WV0049654000Medicaid
A72174Medicare UPIN