Provider Demographics
NPI:1497252373
Name:WISE-EL, CLIFFORD JOE
Entity Type:Individual
Prefix:
First Name:CLIFFORD
Middle Name:JOE
Last Name:WISE-EL
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 1:568 BRUMMEL CT NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20012-1860
Mailing Address - Country:US
Mailing Address - Phone:202-450-2745
Mailing Address - Fax:202-450-2723
Practice Address - Street 1:568 BRUMMEL CT NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20012-1860
Practice Address - Country:US
Practice Address - Phone:202-450-2745
Practice Address - Fax:202-450-2723
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-09
Last Update Date:2018-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD133137332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD$$$$$$$$$Medicaid