Provider Demographics
NPI:1811917693
Name:WISE MEDICAL, INC.
Entity type:Organization
Organization Name:WISE MEDICAL, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ALPHAEUS
Authorized Official - Middle Name:MANSFIELD
Authorized Official - Last Name:WISE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:925-935-3113
Mailing Address - Street 1:1150 CIVIC DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94596-8241
Mailing Address - Country:US
Mailing Address - Phone:925-935-3113
Mailing Address - Fax:925-935-4482
Practice Address - Street 1:1150 CIVIC DR
Practice Address - Street 2:SUITE 100
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94596-8241
Practice Address - Country:US
Practice Address - Phone:925-935-3113
Practice Address - Fax:925-935-4482
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA95309207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty