Provider Demographics
NPI:1588623839
Name:WISE, THOMAS G (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:G
Last Name:WISE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2850 MORNINGSIDE DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT DORA
Mailing Address - State:FL
Mailing Address - Zip Code:32757-6610
Mailing Address - Country:US
Mailing Address - Phone:352-383-0733
Mailing Address - Fax:352-383-7112
Practice Address - Street 1:2850 MORNINGSIDE DR
Practice Address - Street 2:
Practice Address - City:MOUNT DORA
Practice Address - State:FL
Practice Address - Zip Code:32757-6610
Practice Address - Country:US
Practice Address - Phone:352-383-0733
Practice Address - Fax:352-383-7112
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2010-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME36379174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLB99008Medicare UPIN
FL99529AMedicare ID - Type Unspecified