Provider Demographics
NPI:1821162801
Name:WISEMAN, GLORIA DIANA (MD)
Entity Type:Individual
Prefix:DR
First Name:GLORIA
Middle Name:DIANA
Last Name:WISEMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:69 EDGEMONT PLACE
Mailing Address - Street 2:
Mailing Address - City:TEANECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07666-4605
Mailing Address - Country:US
Mailing Address - Phone:201-837-9918
Mailing Address - Fax:201-837-9936
Practice Address - Street 1:570 FORT WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10033-2054
Practice Address - Country:US
Practice Address - Phone:212-795-3293
Practice Address - Fax:212-795-3164
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1511872080N0001X
NJMA479362080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00848417Medicaid
NJ5114900Medicaid
WI 720450Medicare ID - Type Unspecified
NY00848417Medicaid