Provider Demographics
NPI:1790759579
Name:WISE, TERRENCE (MD)
Entity Type:Individual
Prefix:DR
First Name:TERRENCE
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 1:1255 HIGHWAY 54 W
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-4526
Mailing Address - Country:US
Mailing Address - Phone:770-719-5630
Mailing Address - Fax:
Practice Address - Street 1:1255 HIGHWAY 54 W
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-4526
Practice Address - Country:US
Practice Address - Phone:770-719-5630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-16
Last Update Date:2020-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA056246207R00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
2106119OtherHIGHMARK
PA1023118620001Medicaid
I41714Medicare UPIN
2106119OtherHIGHMARK