Provider Demographics
NPI:1548201890
Name:WISNIEWSKI, MARY L (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:L
Last Name:WISNIEWSKI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 986513
Mailing Address - Street 2:DEPARTMENT 100
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02298-6513
Mailing Address - Country:US
Mailing Address - Phone:910-219-8326
Mailing Address - Fax:910-939-4269
Practice Address - Street 1:118 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-6328
Practice Address - Country:US
Practice Address - Phone:910-353-0581
Practice Address - Fax:910-577-1150
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC2010-01227208000000X
NJ25MAO4013000208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics