Provider Demographics
NPI:1801905377
Name:WISE, ARNOLD B (MD)
Entity type:Individual
Prefix:DR
First Name:ARNOLD
Middle Name:B
Last Name:WISE
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 1:1009 SPRUCE ST
Mailing Address - Street 2:
Mailing Address - City:ESPANOLA
Mailing Address - State:NM
Mailing Address - Zip Code:87532-2740
Mailing Address - Country:US
Mailing Address - Phone:505-747-4144
Mailing Address - Fax:505-747-3213
Practice Address - Street 1:1009 SPRUCE ST
Practice Address - Street 2:
Practice Address - City:ESPANOLA
Practice Address - State:NM
Practice Address - Zip Code:87532-2740
Practice Address - Country:US
Practice Address - Phone:505-747-4144
Practice Address - Fax:505-747-3213
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM98-200174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMS6084Medicaid
NMB81638Medicare UPIN