Provider Demographics
NPI:1669453700
Name:WISE, WILLIAM S (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:S
Last Name:WISE
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:460 TOTTEN POND RD
Mailing Address - Street 2:C/O MZI
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02451-1991
Mailing Address - Country:US
Mailing Address - Phone:781-890-9933
Mailing Address - Fax:781-890-9950
Practice Address - Street 1:235 N PEARL ST
Practice Address - Street 2:ATTN: PATHOLOGY DEPT
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-1794
Practice Address - Country:US
Practice Address - Phone:508-427-3086
Practice Address - Fax:508-588-0520
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2010-03-01
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MA57170207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAAA1347OtherHPHC
MAJ03385OtherBCBS
MA6182089Medicaid
MA732320OtherTUFTS
MA6182089Medicaid
MAJ03385OtherBCBS