Provider Demographics
NPI:1558344705
Name:WISE, PHILLIP LEE (OD)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:LEE
Last Name:WISE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:326 N BROAD ST
Mailing Address - Street 2:
Mailing Address - City:SELINSGROVE
Mailing Address - State:PA
Mailing Address - Zip Code:17870-1512
Mailing Address - Country:US
Mailing Address - Phone:570-374-8136
Mailing Address - Fax:570-374-0462
Practice Address - Street 1:326 N BROAD ST
Practice Address - Street 2:
Practice Address - City:SELINSGROVE
Practice Address - State:PA
Practice Address - Zip Code:17870-1512
Practice Address - Country:US
Practice Address - Phone:570-374-8136
Practice Address - Fax:570-374-0462
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG001746152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0012999200001Medicaid
PA02549200OtherCAPITAL BLUE CROSS
PAT28746OtherHEALTH ASSURANCE
PA02549200OtherCAPITAL BLUE CROSS
PA109110F8VMedicare PIN
PAT28746OtherHEALTH ASSURANCE