Provider Demographics
NPI:1720246614
Name:WISE, MELISSA JO (MD)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:JO
Last Name:WISE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:801 YORK ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-4630
Mailing Address - Country:US
Mailing Address - Phone:920-663-9146
Mailing Address - Fax:920-684-1439
Practice Address - Street 1:159 S ENGLISH STATION RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40245-3996
Practice Address - Country:US
Practice Address - Phone:502-753-0056
Practice Address - Fax:502-756-0626
Is Sole Proprietor?:No
Enumeration Date:2008-05-28
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMT190084207N00000X
KY43415207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology