Provider Demographics
NPI:1700863321
Name:WISE, PAMELA M (OD)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:M
Last Name:WISE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 E DAY RD
Mailing Address - Street 2:100
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545-3408
Mailing Address - Country:US
Mailing Address - Phone:574-271-3939
Mailing Address - Fax:574-271-3941
Practice Address - Street 1:230 E DAY RD
Practice Address - Street 2:100
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-3408
Practice Address - Country:US
Practice Address - Phone:574-271-3939
Practice Address - Fax:574-271-3941
Is Sole Proprietor?:No
Enumeration Date:2005-12-23
Last Update Date:2013-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002843A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN18002843AOtherOPTOMETRIST LICENSE
IN200149240Medicaid
INP00014932OtherRR MEDICARE
IN4823160004Medicare NSC
IN4823160003Medicare NSC
IN4823160002Medicare NSC
IN4823160001Medicare NSC
INU65033Medicare UPIN
IN204460PMedicare PIN