Provider Demographics
NPI:1982705570
Name:WISE, LOUIS JULIAN JR (MD)
Entity Type:Individual
Prefix:DR
First Name:LOUIS
Middle Name:JULIAN
Last Name:WISE
Suffix:JR
Gender:M
Credentials:MD
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Mailing Address - Street 1:3000 OLD CANTON ROAD
Mailing Address - Street 2:SUITE 430
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216
Mailing Address - Country:US
Mailing Address - Phone:601-982-5441
Mailing Address - Fax:601-982-5442
Practice Address - Street 1:3000 OLD CANTON ROAD
Practice Address - Street 2:SUITE 430
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216
Practice Address - Country:US
Practice Address - Phone:601-982-5441
Practice Address - Fax:601-982-5442
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
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Provider Licenses
StateLicense IDTaxonomies
MS003970207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
C48183Medicare UPIN