Provider Demographics
NPI:1942359658
Name:WISDOM, JOHN DEREK (DC)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:DEREK
Last Name:WISDOM
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1018 E GOODE ST STE 102
Mailing Address - Street 2:
Mailing Address - City:QUITMAN
Mailing Address - State:TX
Mailing Address - Zip Code:75783
Mailing Address - Country:US
Mailing Address - Phone:903-763-4404
Mailing Address - Fax:903-763-2550
Practice Address - Street 1:1018 E GOODE ST STE 102
Practice Address - Street 2:
Practice Address - City:QUITMAN
Practice Address - State:SD
Practice Address - Zip Code:75783
Practice Address - Country:US
Practice Address - Phone:903-763-4404
Practice Address - Fax:903-763-2550
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX7361111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0020166-01Medicaid
TX0020166-01Medicaid
TX605747Medicare Oscar/Certification