Provider Demographics
NPI:1265537005
Name:WISEMAN, ESHAGH (MD)
Entity type:Individual
Prefix:DR
First Name:ESHAGH
Middle Name:
Last Name:WISEMAN
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 1:21 CARY RD
Mailing Address - Street 2:
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-1517
Mailing Address - Country:US
Mailing Address - Phone:516-946-8333
Mailing Address - Fax:
Practice Address - Street 1:21 CARY RD
Practice Address - Street 2:
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-1517
Practice Address - Country:US
Practice Address - Phone:516-946-8333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2012-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY137450208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01131286Medicaid
E39104Medicare UPIN
NY01131286Medicaid