Provider Demographics
NPI:1619971520
Name:WISE, RICHARD B (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:B
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 1:54 W JIMMIE LEEDS RD # 15
Mailing Address - Street 2:
Mailing Address - City:GALLOWAY
Mailing Address - State:NJ
Mailing Address - Zip Code:08205-9401
Mailing Address - Country:US
Mailing Address - Phone:609-652-1010
Mailing Address - Fax:
Practice Address - Street 1:54 WEST JIMMIE LEEDS RD
Practice Address - Street 2:UNIT 15
Practice Address - City:GALLOWAY
Practice Address - State:NJ
Practice Address - Zip Code:08205-9401
Practice Address - Country:US
Practice Address - Phone:609-652-1010
Practice Address - Fax:609-652-7759
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-08
Last Update Date:2008-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA72455207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ60000622OtherHORIZON MERCY
NJ8640408Medicaid
2398350000OtherAMERIHEALTH
3840133OtherAETNA HMO
NJH21519Medicare UPIN
2398350000OtherAMERIHEALTH
NJ5448710001Medicare NSC