Provider Demographics
NPI:1588201420
Name:WISE, WILLIAM
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:
Last Name:WISE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 NORTH ST
Mailing Address - Street 2:
Mailing Address - City:OTISVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48463-9705
Mailing Address - Country:US
Mailing Address - Phone:810-374-6410
Mailing Address - Fax:
Practice Address - Street 1:410 NORTH ST
Practice Address - Street 2:
Practice Address - City:OTISVILLE
Practice Address - State:MI
Practice Address - Zip Code:48463-9705
Practice Address - Country:US
Practice Address - Phone:810-374-6410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-10
Last Update Date:2019-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician