Provider Demographics
NPI:1568597086
Name:JONATHAN T WISEMAN DO PA
Entity Type:Organization
Organization Name:JONATHAN T WISEMAN DO PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WISEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:856-761-0766
Mailing Address - Street 1:129 BRIDGEBORO ST
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:NJ
Mailing Address - Zip Code:08075-3201
Mailing Address - Country:US
Mailing Address - Phone:856-461-0766
Mailing Address - Fax:215-523-9281
Practice Address - Street 1:129 BRIDGEBORO ST
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:NJ
Practice Address - Zip Code:08075-3201
Practice Address - Country:US
Practice Address - Phone:856-461-0766
Practice Address - Fax:215-523-9281
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-23
Last Update Date:2011-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty