Provider Demographics
NPI:1255181467
Name:WISNIEWSKI, KEVIN RALPH (DO)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:RALPH
Last Name:WISNIEWSKI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2213 CHERRY ST
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43608-2603
Mailing Address - Country:US
Mailing Address - Phone:419-251-3232
Mailing Address - Fax:
Practice Address - Street 1:7045 LIGHTHOUSE WAY
Practice Address - Street 2:
Practice Address - City:PERRYSBURG
Practice Address - State:OH
Practice Address - Zip Code:43551-7000
Practice Address - Country:US
Practice Address - Phone:419-873-6836
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-22
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH58.033927390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program