Provider Demographics
NPI:1134259849
Name:WISE, DAVID LEO (MD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:LEO
Last Name:WISE
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 1:115 S 15TH AVE
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4068
Mailing Address - Country:US
Mailing Address - Phone:208-234-0012
Mailing Address - Fax:208-478-7877
Practice Address - Street 1:115 S 15TH AVE
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4068
Practice Address - Country:US
Practice Address - Phone:208-234-0012
Practice Address - Fax:208-478-7877
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-3654207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID3654-1OtherBLUE CROSS OF IDAHO
ID3654-1OtherBLUE CROSS OF IDAHO
IDC36846Medicare UPIN