Provider Demographics
NPI:1972594083
Name:WISOTSKY, BURTON JUDAH (MD)
Entity Type:Individual
Prefix:
First Name:BURTON
Middle Name:JUDAH
Last Name:WISOTSKY
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 1:485 ROUTE 1 S
Mailing Address - Street 2:BLDG A
Mailing Address - City:ISELIN
Mailing Address - State:NJ
Mailing Address - Zip Code:08830-3009
Mailing Address - Country:US
Mailing Address - Phone:732-750-0400
Mailing Address - Fax:732-750-1507
Practice Address - Street 1:485 ROUTE 1 S
Practice Address - Street 2:BLDG A
Practice Address - City:ISELIN
Practice Address - State:NJ
Practice Address - Zip Code:08830-3009
Practice Address - Country:US
Practice Address - Phone:732-750-0400
Practice Address - Fax:732-750-1507
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2017-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06274100207W00000X, 207WX0107X
NY1869411207W00000X
NY186941-1207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6675905Medicaid
NY01634931Medicaid
NY7871714QHYOtherMEDICARE
NYBW073T7610OtherNY CARE
NJ787171MP7Medicare ID - Type Unspecified
NJ6675905Medicaid
NJ7871714QHYMedicare PIN
NY01634931Medicaid