Provider Demographics
NPI:1780627414
Name:WISE, DAVID S (MD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:S
Last Name:WISE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 460625
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78246-0625
Mailing Address - Country:US
Mailing Address - Phone:210-258-5009
Mailing Address - Fax:210-368-9440
Practice Address - Street 1:11606 MILL ROCK RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78230-2762
Practice Address - Country:US
Practice Address - Phone:210-258-5009
Practice Address - Fax:210-368-9440
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-13
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMDH8963207RC0000X
TXH8963207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0063CNOtherBLUE CROSS ID NUMBER
TX113351401Medicaid
TX060050641OtherRAILROAD MEDICARE NUMBER
TX113351401Medicaid