Provider Demographics
NPI:1831252014
Name:WISE, KENDALL L (MD)
Entity type:Individual
Prefix:
First Name:KENDALL
Middle Name:L
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 1:2234 COLONIAL BLVD
Mailing Address - Street 2:MANAGED CARE DEPT.
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1412
Mailing Address - Country:US
Mailing Address - Phone:239-931-7342
Mailing Address - Fax:239-931-7385
Practice Address - Street 1:1044 GOODLETTE RD N.
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34102
Practice Address - Country:US
Practice Address - Phone:239-261-5400
Practice Address - Fax:239-261-4387
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2016-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME53290208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL5340047OtherAETNA PROVIDER ID
FL05823OtherBCBS
FL038093800Medicaid
FL1193523OtherWELLCARE
FLP00796370OtherRAILROAD MEDICARE
FL05823OtherBCBS FL
FL340007341OtherRRMC
FL315207OtherAVMED
FL05823ZMedicare PIN
FL315207OtherAVMED
FL340007341OtherRRMC