Provider Demographics
NPI:1497800304
Name:WISEMAN, RICHARD JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:JOHN
Last Name:WISEMAN
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 1:2500 S LAKELINE BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:CEDAR PARK
Mailing Address - State:TX
Mailing Address - Zip Code:78613-2968
Mailing Address - Country:US
Mailing Address - Phone:512-345-8970
Mailing Address - Fax:512-345-6689
Practice Address - Street 1:2500 S LAKELINE BLVD STE 100
Practice Address - Street 2:
Practice Address - City:CEDAR PARK
Practice Address - State:TX
Practice Address - Zip Code:78613-2968
Practice Address - Country:US
Practice Address - Phone:512-345-8970
Practice Address - Fax:512-345-6689
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2018-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF0084207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
742178955OtherEIN
00HH79Medicare ID - Type Unspecified
B27627Medicare UPIN