Provider Demographics
NPI:1710931738
Name:WISCH, DOUGLAS C (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:C
Last Name:WISCH
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 1:245 ALVORD PARK RD
Mailing Address - Street 2:
Mailing Address - City:TORRINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06790
Mailing Address - Country:US
Mailing Address - Phone:860-482-8539
Mailing Address - Fax:860-482-0258
Practice Address - Street 1:245 ALVORD PARK RD
Practice Address - Street 2:
Practice Address - City:TORRINGTON
Practice Address - State:CT
Practice Address - Zip Code:06790
Practice Address - Country:US
Practice Address - Phone:860-482-8539
Practice Address - Fax:860-482-0258
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT032872207X00000X, 207XS0106X, 2086S0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No2086S0105XAllopathic & Osteopathic PhysiciansSurgerySurgery of the Hand
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT010032872CT01OtherBC
CT2205151OtherAETNA
CT001328724Medicaid
F01248Medicare UPIN
CT200000905Medicare PIN