Provider Demographics
NPI:1568542363
Name:WISE, DOUGLAS JAMES (DO)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:JAMES
Last Name:WISE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40285 WINCHESTER RD
Mailing Address - Street 2:#103
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92591-5547
Mailing Address - Country:US
Mailing Address - Phone:951-296-5844
Mailing Address - Fax:951-296-5840
Practice Address - Street 1:40285 WINCHESTER RD
Practice Address - Street 2:#103
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92591-5547
Practice Address - Country:US
Practice Address - Phone:951-296-5844
Practice Address - Fax:951-296-5840
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA20A5399207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX53990Medicaid
20A53990Medicare ID - Type Unspecified
CA00AX53990Medicaid