Provider Demographics
NPI:1356323323
Name:WISEMAN, WILLIAM J (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:J
Last Name:WISEMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:610 E SOUTHPORT RD
Practice Address - Street 2:STE 200
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46227-8590
Practice Address - Country:US
Practice Address - Phone:317-781-4588
Practice Address - Fax:317-782-4885
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN01038528A2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200020140AMedicaid
F09182Medicare UPIN
IN677340BMedicare ID - Type Unspecified