Provider Demographics
NPI:1407838451
Name:WISNICKI, HERBERT JAY (MD)
Entity Type:Individual
Prefix:
First Name:HERBERT
Middle Name:JAY
Last Name:WISNICKI
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 1:235 PARK AVE S
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10003-1405
Mailing Address - Country:US
Mailing Address - Phone:212-844-2020
Mailing Address - Fax:
Practice Address - Street 1:235 PARK AVE S
Practice Address - Street 2:2ND FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-1405
Practice Address - Country:US
Practice Address - Phone:212-844-2020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-16
Last Update Date:2018-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY150650152W00000X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00970627Medicaid
B79286Medicare UPIN
NY00970627Medicaid