Provider Demographics
NPI:1528000783
Name:WISBACH, GORDON G III (MD)
Entity Type:Individual
Prefix:DR
First Name:GORDON
Middle Name:G
Last Name:WISBACH
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:4442 VEREDA LUNA LLENA
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92130-2666
Mailing Address - Country:US
Mailing Address - Phone:619-823-9678
Mailing Address - Fax:
Practice Address - Street 1:34800 BOB WILSON DRIVE
Practice Address - Street 2:NMCSD
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92134
Practice Address - Country:US
Practice Address - Phone:619-532-7579
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2014-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA75212208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery