Provider Demographics
NPI:1689610669
Name:WISE, THOMAS (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:
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:INOVA FAIRFAX HOSPITAL
Mailing Address - Street 2:3300 GALLOWS ROAD
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22042-3300
Mailing Address - Country:US
Mailing Address - Phone:703-776-3626
Mailing Address - Fax:703-776-3029
Practice Address - Street 1:INOVA FAIRFAX HOSPITAL
Practice Address - Street 2:3300 GALLOWS ROAD
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22042-3300
Practice Address - Country:US
Practice Address - Phone:703-776-3626
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD153862084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD920006100Medicaid
MDH897C599Medicare ID - Type Unspecified
MD920006100Medicaid