Provider Demographics
NPI:1558586818
Name:JON M WISEMAN MD PC
Entity Type:Organization
Organization Name:JON M WISEMAN MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JON
Authorized Official - Middle Name:MARTIN
Authorized Official - Last Name:WISEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:202-966-8868
Mailing Address - Street 1:5410 CONNECTICUT AVE NW
Mailing Address - Street 2:SUITE 117
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20015-2859
Mailing Address - Country:US
Mailing Address - Phone:202-966-8868
Mailing Address - Fax:202-244-3071
Practice Address - Street 1:5410 CONNECTICUT AVE NW
Practice Address - Street 2:SUITE 117
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20015-2859
Practice Address - Country:US
Practice Address - Phone:202-966-8868
Practice Address - Fax:202-244-3071
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-13
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC12890207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC595317Medicare PIN
DCC61959Medicare UPIN