Provider Demographics
NPI:1710969985
Name:WISELEY, RICHARD J (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:J
Last Name:WISELEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3425 EXECUTIVE PKWY STE 107
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43606-1333
Mailing Address - Country:US
Mailing Address - Phone:419-535-7798
Mailing Address - Fax:419-535-6624
Practice Address - Street 1:3425 EXECUTIVE PKWY
Practice Address - Street 2:STE 107
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43606-1326
Practice Address - Country:US
Practice Address - Phone:419-535-7798
Practice Address - Fax:419-535-6654
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35025209207RA0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0201XAllopathic & Osteopathic PhysiciansInternal MedicineAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0074360Medicaid
OH0074360Medicaid
A70695Medicare UPIN
OHWI0126182Medicare PIN