Provider Demographics
NPI:1497754592
Name:WISE, CARLOS RODRIGUEZ (MD)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:RODRIGUEZ
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:PO BOX 1038
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31902-1038
Mailing Address - Country:US
Mailing Address - Phone:706-571-1120
Mailing Address - Fax:706-660-1603
Practice Address - Street 1:1800 10TH AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31901-1513
Practice Address - Country:US
Practice Address - Phone:706-571-1120
Practice Address - Fax:706-660-1603
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2014-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA046925207Q00000X
AL00026131207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA481686160BMedicaid
GA481686160EMedicaid
AL009964375Medicaid
GA876520OtherBC/BS GEORGIA
GA08CBCGMMedicare PIN
GA481686160BMedicaid