Provider Demographics
NPI:1346760436
Name:WISE, STEPHEN HEBERT (OD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:HEBERT
Last Name:WISE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 RUNNING STREAM RD
Mailing Address - Street 2:
Mailing Address - City:REHOBOTH
Mailing Address - State:MA
Mailing Address - Zip Code:02769-1327
Mailing Address - Country:US
Mailing Address - Phone:318-268-5608
Mailing Address - Fax:
Practice Address - Street 1:940 BELMONT ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-5596
Practice Address - Country:US
Practice Address - Phone:508-583-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-21
Last Update Date:2020-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIODTG00640152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist