Provider Demographics
NPI:1922460161
Name:WISHIK, JARED (MD)
Entity Type:Individual
Prefix:
First Name:JARED
Middle Name:
Last Name:WISHIK
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 1:4651 VAN DYKE RD
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33558-4880
Mailing Address - Country:US
Mailing Address - Phone:813-321-1786
Mailing Address - Fax:813-321-1787
Practice Address - Street 1:5200 SEMINOLE BLVD
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33708-3356
Practice Address - Country:US
Practice Address - Phone:813-321-1786
Practice Address - Fax:813-321-1787
Is Sole Proprietor?:No
Enumeration Date:2016-03-27
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125069551207N00000X
FLM144461207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology