Provider Demographics
NPI:1558821496
Name:WISA, DEENA MARIE (MD)
Entity Type:Individual
Prefix:
First Name:DEENA
Middle Name:MARIE
Last Name:WISA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 N SHORE DR
Mailing Address - Street 2:
Mailing Address - City:HILTON
Mailing Address - State:NY
Mailing Address - Zip Code:14468-8802
Mailing Address - Country:US
Mailing Address - Phone:585-261-0677
Mailing Address - Fax:
Practice Address - Street 1:60 GREECE CENTER DR STE 4
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14612-1358
Practice Address - Country:US
Practice Address - Phone:585-602-0100
Practice Address - Fax:585-453-9240
Is Sole Proprietor?:No
Enumeration Date:2019-03-25
Last Update Date:2023-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY320729207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine