Provider Demographics
NPI:1205849866
Name:WISDOM, DARYL D (MD)
Entity type:Individual
Prefix:
First Name:DARYL
Middle Name:D
Last Name:WISDOM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:10015 CASCADE RD SE
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:MI
Mailing Address - Zip Code:49331-9529
Mailing Address - Country:US
Mailing Address - Phone:616-868-7551
Mailing Address - Fax:616-868-7321
Practice Address - Street 1:10015 CASCADE RD SE
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MI
Practice Address - Zip Code:49331-9529
Practice Address - Country:US
Practice Address - Phone:616-868-7551
Practice Address - Fax:616-868-7321
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2016-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301048819207PE0004X, 2083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIB43232Medicare UPIN