Provider Demographics
NPI:1346543345
Name:WISE, JOHN D III
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:D
Last Name:WISE
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 E NORTHSIDE DR
Mailing Address - Street 2:SUITE D
Mailing Address - City:CLINTON
Mailing Address - State:MS
Mailing Address - Zip Code:39056-3437
Mailing Address - Country:US
Mailing Address - Phone:601-925-9473
Mailing Address - Fax:601-925-9490
Practice Address - Street 1:600 E NORTHSIDE DR
Practice Address - Street 2:SUITE D
Practice Address - City:CLINTON
Practice Address - State:MS
Practice Address - Zip Code:39056-3437
Practice Address - Country:US
Practice Address - Phone:601-925-9473
Practice Address - Fax:601-925-9490
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-13
Last Update Date:2011-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS5337740001332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02053764Medicaid
MS02053764Medicaid