Provider Demographics
NPI:1457517831
Name:WISE, BRET D (OD)
Entity Type:Individual
Prefix:
First Name:BRET
Middle Name:D
Last Name:WISE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:321 S HILLSIDE
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67211-2130
Mailing Address - Country:US
Mailing Address - Phone:316-685-1898
Mailing Address - Fax:316-685-4170
Practice Address - Street 1:321 S HILLSIDE ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67211-2130
Practice Address - Country:US
Practice Address - Phone:316-685-1898
Practice Address - Fax:316-685-4170
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-05
Last Update Date:2015-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1831152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS0248130001Medicare NSC
KS017097002Medicare PIN