Provider Demographics
NPI:1508862509
Name:WISOTSKY, PHILIP (MD)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:
Last Name:WISOTSKY
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 1:11350 PEMBROOKE SQ STE 311
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20603-4809
Mailing Address - Country:US
Mailing Address - Phone:301-870-0660
Mailing Address - Fax:301-932-8310
Practice Address - Street 1:11350 PEMBROOKE SQ STE 311
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20603-4809
Practice Address - Country:US
Practice Address - Phone:301-870-0660
Practice Address - Fax:301-932-8310
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2021-11-19
Deactivation Date:2006-03-16
Deactivation Code:
Reactivation Date:2006-03-31
Provider Licenses
StateLicense IDTaxonomies
MDD18545207RG0300X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD960821400Medicaid
110167788OtherRR MEDICARE
110167788OtherRR MEDICARE
MD960821400Medicaid
DC000C99P76Medicare PIN