Provider Demographics
NPI:1417979816
Name:WISE, TIMOTHY CHARLES (OD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:CHARLES
Last Name:WISE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1285 DOLLY PARTON PKWY
Mailing Address - Street 2:
Mailing Address - City:SEVIERVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37862-3705
Mailing Address - Country:US
Mailing Address - Phone:865-453-3619
Mailing Address - Fax:865-428-5168
Practice Address - Street 1:1285 DOLLY PARTON PKWY
Practice Address - Street 2:
Practice Address - City:SEVIERVILLE
Practice Address - State:TN
Practice Address - Zip Code:37862-3705
Practice Address - Country:US
Practice Address - Phone:865-453-3619
Practice Address - Fax:865-428-5168
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2008-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNODT1181152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4148974OtherBLUE CROSS BLUE SHIELD TN
TN35966431Medicaid
TNT81674Medicare UPIN
TN0278010002Medicare NSC
TN35966431Medicare PIN