Provider Demographics
NPI:1407982721
Name:WISE, LARRY KEITH (MD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:KEITH
Last Name:WISE
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 1:2336 GODDARD PKWY
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21801-1126
Mailing Address - Country:US
Mailing Address - Phone:410-334-6961
Mailing Address - Fax:410-334-6362
Practice Address - Street 1:2336 GODDARD PKWY
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21801-1126
Practice Address - Country:US
Practice Address - Phone:410-334-6961
Practice Address - Fax:410-334-6362
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2011-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD261742084P0800X
MDD00514582084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR930593249OtherGROUP TAX ID #
MD609550001Medicaid
MD609550002Medicaid
OR1225016561OtherGROUP NPI #
MD609550004Medicaid
MDLM49EAOtherCAREFIRST BCBS LOCAL
MDR968OtherCAREFIRST BCBS
MD742LMedicare PIN
MDLM49EAOtherCAREFIRST BCBS LOCAL
OR1225016561OtherGROUP NPI #