Provider Demographics
NPI:1154732725
Name:WISEMAN, MARK
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:WISEMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 TEXAS ST APT 8D
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77002-3136
Mailing Address - Country:US
Mailing Address - Phone:607-742-2257
Mailing Address - Fax:
Practice Address - Street 1:1247 S. CEDAR CREST BLVD
Practice Address - Street 2:
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18103
Practice Address - Country:US
Practice Address - Phone:610-482-2570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-16
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT206443207P00000X, 208600000X
TXS2540207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208600000XAllopathic & Osteopathic PhysiciansSurgery