Provider Demographics
NPI:1477556496
Name:WISE, JOHN MELVIN (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:MELVIN
Last Name:WISE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:2820 NAPOLEON AVE
Mailing Address - Street 2:STE 460
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70115
Mailing Address - Country:US
Mailing Address - Phone:504-897-5121
Mailing Address - Fax:504-897-9743
Practice Address - Street 1:2820 NAPOLEON AVE
Practice Address - Street 2:STE 460
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70115
Practice Address - Country:US
Practice Address - Phone:504-897-5121
Practice Address - Fax:504-897-9743
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-23
Last Update Date:2016-02-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LA12877R207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
5255663OtherAETNA
110220987OtherRAILROAD MEDICARE
0000204504201OtherUNITED HEALTHCARE
LA1545759Medicaid
LA0401526OtherUNITED HEALTHCARE OF LA
LA5E111CR53Medicare PIN
LAG82806Medicare UPIN
LA5E111Medicare PIN