Provider Demographics
NPI:1912987355
Name:WISEMAN, DOUGLAS FENTON (MD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:FENTON
Last Name:WISEMAN
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 1:6836 COOKES HOPE RD
Mailing Address - Street 2:
Mailing Address - City:EASTON
Mailing Address - State:MD
Mailing Address - Zip Code:21601-8302
Mailing Address - Country:US
Mailing Address - Phone:410-690-0975
Mailing Address - Fax:
Practice Address - Street 1:6836 COOKES HOPE RD
Practice Address - Street 2:
Practice Address - City:EASTON
Practice Address - State:MD
Practice Address - Zip Code:21601-8302
Practice Address - Country:US
Practice Address - Phone:410-690-0975
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-20
Last Update Date:2020-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0070552207L00000X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3514606Medicaid
OM71590041Medicare ID - Type Unspecified
E49559Medicare UPIN