Provider Demographics
NPI:1831126663
Name:WISE, THOMAS WATKINS (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:WATKINS
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 1:128 MEDICAL CIR
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:22601-3322
Mailing Address - Country:US
Mailing Address - Phone:540-667-8975
Mailing Address - Fax:540-667-6589
Practice Address - Street 1:128 MEDICAL CIR
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:VA
Practice Address - Zip Code:22601-3322
Practice Address - Country:US
Practice Address - Phone:540-667-8975
Practice Address - Fax:540-667-6589
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101227106207X00000X, 207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
200039661OtherMEDICARE RAILROAD
P00776570OtherRAILROAD MEDICARE
VA6401686Medicaid
200039661OtherMEDICARE RAILROAD
VA6401686Medicaid
VA6289760001Medicare NSC
VA00Y062W01Medicare PIN