Provider Demographics
NPI:1245251263
Name:WISE, MATTHEW WHITTEN (MD)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:WHITTEN
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 1:2820 NAPOLEON AVE
Mailing Address - Street 2:SUITE 810
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70115-6969
Mailing Address - Country:US
Mailing Address - Phone:504-412-1310
Mailing Address - Fax:504-899-8496
Practice Address - Street 1:2820 NAPOLEON AVE
Practice Address - Street 2:SUITE 810
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70115-6969
Practice Address - Country:US
Practice Address - Phone:504-412-1310
Practice Address - Fax:504-899-8496
Is Sole Proprietor?:No
Enumeration Date:2006-07-23
Last Update Date:2010-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA024879208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1570877Medicaid
MS07133512Medicaid
MS07133512Medicaid
LA4A807F669Medicare PIN
LA1570877Medicaid
LA4A807F668Medicare PIN
LA4A807Medicare PIN