Provider Demographics
NPI:1598802761
Name:WISE, ROBERT BOYD (DC)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:BOYD
Last Name:WISE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:332 NORTH AVENUE
Mailing Address - Street 2:
Mailing Address - City:GARWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07027
Mailing Address - Country:US
Mailing Address - Phone:908-789-2303
Mailing Address - Fax:908-789-2304
Practice Address - Street 1:332 NORTH AVENUE
Practice Address - Street 2:
Practice Address - City:GARWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07027
Practice Address - Country:US
Practice Address - Phone:908-789-2303
Practice Address - Fax:908-789-2304
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ1996NJ111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
192676Medicare ID - Type Unspecified
W24632Medicare UPIN