Provider Demographics
NPI:1184624371
Name:WISDOM, GREGORY S (MD)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:S
Last Name:WISDOM
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:110 N BEDFORD RD
Mailing Address - Street 2:CAREMOUNT MEDICAL, PC
Mailing Address - City:MOUNT KISCO
Mailing Address - State:NY
Mailing Address - Zip Code:10549
Mailing Address - Country:US
Mailing Address - Phone:914-241-1050
Mailing Address - Fax:914-232-7588
Practice Address - Street 1:111 BEDFORD RD
Practice Address - Street 2:CAREMOUNT MEDICAL, PC
Practice Address - City:KATONAH
Practice Address - State:NY
Practice Address - Zip Code:10536-2115
Practice Address - Country:US
Practice Address - Phone:914-241-1050
Practice Address - Fax:914-232-7588
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2016-10-19
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Provider Licenses
StateLicense IDTaxonomies
NY201012207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01873656Medicaid
NYG72248Medicare UPIN
NY05Z3706761Medicare PIN