Provider Demographics
NPI:1548231269
Name:WISNIEWSKI, PETER F I (DO)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:F
Last Name:WISNIEWSKI
Suffix:I
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:518 WEST DR
Mailing Address - Street 2:
Mailing Address - City:OKOLONA
Mailing Address - State:MS
Mailing Address - Zip Code:38860-1624
Mailing Address - Country:US
Mailing Address - Phone:662-447-1339
Mailing Address - Fax:662-447-1386
Practice Address - Street 1:518 WEST DR
Practice Address - Street 2:
Practice Address - City:OKOLONA
Practice Address - State:MS
Practice Address - Zip Code:38860-1624
Practice Address - Country:US
Practice Address - Phone:662-447-1339
Practice Address - Fax:662-447-1386
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-31
Last Update Date:2009-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS08960207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07728748Medicaid
MS07728748Medicaid
MSD80494Medicare UPIN