Provider Demographics
NPI:1417926122
Name:WISE, WARREN PAUL
Entity Type:Individual
Prefix:DR
First Name:WARREN
Middle Name:PAUL
Last Name:WISE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1270 RIBAUT RD
Mailing Address - Street 2:
Mailing Address - City:BEAUFORT
Mailing Address - State:SC
Mailing Address - Zip Code:29902-6143
Mailing Address - Country:US
Mailing Address - Phone:843-525-9473
Mailing Address - Fax:843-525-1108
Practice Address - Street 1:1270 RIBAUT RD
Practice Address - Street 2:
Practice Address - City:BEAUFORT
Practice Address - State:SC
Practice Address - Zip Code:29902-6143
Practice Address - Country:US
Practice Address - Phone:843-525-9473
Practice Address - Fax:843-525-1108
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-15
Last Update Date:2010-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1051152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCU651740281Medicare UPIN
SCU943260281Medicare UPIN