Provider Demographics
NPI:1972506558
Name:WISEMAN, FREDERICK (DPM)
Entity Type:Individual
Prefix:
First Name:FREDERICK
Middle Name:
Last Name:WISEMAN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 730
Mailing Address - Street 2:
Mailing Address - City:STURGIS
Mailing Address - State:MI
Mailing Address - Zip Code:49091-0730
Mailing Address - Country:US
Mailing Address - Phone:269-651-2320
Mailing Address - Fax:269-659-4704
Practice Address - Street 1:102 S LAKEVIEW AVE
Practice Address - Street 2:
Practice Address - City:STURGIS
Practice Address - State:MI
Practice Address - Zip Code:49091-1947
Practice Address - Country:US
Practice Address - Phone:269-651-2320
Practice Address - Fax:269-659-4704
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2012-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901000866213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOP45860Medicare PIN