Provider Demographics
NPI:1821542986
Name:TIMOTHY C. WISE, O.D.
Entity Type:Organization
Organization Name:TIMOTHY C. WISE, O.D.
Other - Org Name:WISE EYECARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JAYNE
Authorized Official - Middle Name:HUTSELL
Authorized Official - Last Name:WISE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:865-453-3619
Mailing Address - Street 1:1285 DOLLY PARTON PKWY
Mailing Address - Street 2:
Mailing Address - City:SEVIERVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37862-3705
Mailing Address - Country:US
Mailing Address - Phone:865-453-3619
Mailing Address - Fax:865-428-5168
Practice Address - Street 1:1285 DOLLY PARTON PKWY
Practice Address - Street 2:
Practice Address - City:SEVIERVILLE
Practice Address - State:TN
Practice Address - Zip Code:37862-3705
Practice Address - Country:US
Practice Address - Phone:865-453-3619
Practice Address - Fax:865-428-5168
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-06
Last Update Date:2016-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNODT1181152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ021037Medicaid
TNT81674Medicare UPIN
TNQ021037Medicaid
TN0278010002Medicare NSC