Provider Demographics
NPI:1407299555
Name:WISHART, BRIAN DOMENIC (DO)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:DOMENIC
Last Name:WISHART
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3438 BOWMAN ST APT 1
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19129-1509
Mailing Address - Country:US
Mailing Address - Phone:516-297-0530
Mailing Address - Fax:
Practice Address - Street 1:55 FRUIT ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2621
Practice Address - Country:US
Practice Address - Phone:617-724-7168
Practice Address - Fax:617-228-4302
Is Sole Proprietor?:No
Enumeration Date:2013-04-08
Last Update Date:2018-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PAOS018121208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program