Provider Demographics
NPI:1972538460
Name:JOHN D WISE III
Entity Type:Organization
Organization Name:JOHN D WISE III
Other - Org Name:COMFORTWISE FOOTWEAR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRINCIPAL
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:DURR
Authorized Official - Last Name:WISE
Authorized Official - Suffix:III
Authorized Official - Credentials:C PED
Authorized Official - Phone:601-925-9473
Mailing Address - Street 1:600 E NORTHSIDE DR
Mailing Address - Street 2:SUITE D
Mailing Address - City:CLINTON
Mailing Address - State:MS
Mailing Address - Zip Code:39056-3437
Mailing Address - Country:US
Mailing Address - Phone:601-925-9473
Mailing Address - Fax:601-925-9490
Practice Address - Street 1:600 E NORTHSIDE DR
Practice Address - Street 2:SUITE D
Practice Address - City:CLINTON
Practice Address - State:MS
Practice Address - Zip Code:39056-3437
Practice Address - Country:US
Practice Address - Phone:601-925-9473
Practice Address - Fax:601-925-9490
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-12
Last Update Date:2010-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02053764Medicaid
MS02053764Medicaid