Provider Demographics
NPI:1700903390
Name:WISE, DANIEL THOMAS (DC)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:THOMAS
Last Name:WISE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 38
Mailing Address - Street 2:14307 JARRETTSVILLE PIKE
Mailing Address - City:PHOENIX
Mailing Address - State:MD
Mailing Address - Zip Code:21131-0038
Mailing Address - Country:US
Mailing Address - Phone:410-592-7300
Mailing Address - Fax:410-666-0348
Practice Address - Street 1:14307 JARRETTSVILLE PIKE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:MD
Practice Address - Zip Code:21131-1763
Practice Address - Country:US
Practice Address - Phone:410-592-7300
Practice Address - Fax:410-666-0348
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC004959111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD192539OtherCOVENTRY HEALTH INSURANCE
MDLY34OtherCAREFIRST-BLUE CROSS
MDR130OtherFEDERAL-CAREFIRST
MDR130OtherFEDERAL-CAREFIRST