Provider Demographics
NPI:1619389939
Name:WISHY, ANDREW MICHAEL (DO)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:MICHAEL
Last Name:WISHY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3551 ROGER BROOKE DR
Mailing Address - Street 2:
Mailing Address - City:FORT SAM HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:78234-4504
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2728 SUNSET BLVD STE 400
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-4872
Practice Address - Country:US
Practice Address - Phone:803-936-7095
Practice Address - Fax:803-936-7908
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-21
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXS89342086S0129X
NMA-2473-212086S0129X
MS299262086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09334325Medicaid