Provider Demographics
NPI:1912157637
Name:WISDOM, DOUGLAS DEAN (PT)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:DEAN
Last Name:WISDOM
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:426 N IMPERIAL AVE
Mailing Address - Street 2:
Mailing Address - City:EL CENTRO
Mailing Address - State:CA
Mailing Address - Zip Code:92243-2329
Mailing Address - Country:US
Mailing Address - Phone:760-592-8148
Mailing Address - Fax:
Practice Address - Street 1:426 N IMPERIAL AVE
Practice Address - Street 2:
Practice Address - City:EL CENTRO
Practice Address - State:CA
Practice Address - Zip Code:92243-2329
Practice Address - Country:US
Practice Address - Phone:760-592-8148
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-30
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT10870225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist