Provider Demographics
NPI:1639127434
Name:WISEMAN, MARK D (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:D
Last Name:WISEMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:100 WILLOW PLZ
Mailing Address - Street 2:SUITE 201
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93291-6206
Mailing Address - Country:US
Mailing Address - Phone:559-627-9284
Mailing Address - Fax:559-713-0965
Practice Address - Street 1:100 WILLOW PLZ
Practice Address - Street 2:SUITE 201
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93291-6206
Practice Address - Country:US
Practice Address - Phone:559-627-9284
Practice Address - Fax:559-713-0965
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-04
Last Update Date:2007-11-14
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAG79867207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0067850Medicaid
CAZZZ47930ZMedicare ID - Type UnspecifiedMEDICARE
CAGR0067850Medicaid