Provider Demographics
NPI:1982696563
Name:WISE, HEIDI E (OD)
Entity Type:Individual
Prefix:DR
First Name:HEIDI
Middle Name:E
Last Name:WISE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 PINE LAKE RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68512-3692
Mailing Address - Country:US
Mailing Address - Phone:402-421-7773
Mailing Address - Fax:402-421-7859
Practice Address - Street 1:1501 PINE LAKE RD
Practice Address - Street 2:SUITE 1
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68512-3692
Practice Address - Country:US
Practice Address - Phone:402-421-7773
Practice Address - Fax:402-421-7859
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2007-07-08
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-04-12
Provider Licenses
StateLicense IDTaxonomies
NE1124152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE100249863-00Medicaid
NE100249863-00Medicaid
NEU73422Medicare UPIN