Provider Demographics
NPI:1063548154
Name:WISEMAN, JONATHAN T (DO)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:T
Last Name:WISEMAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:129 BRIDGEBORO ST
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:NJ
Mailing Address - Zip Code:08075-3201
Mailing Address - Country:US
Mailing Address - Phone:856-461-0766
Mailing Address - Fax:856-461-7095
Practice Address - Street 1:129 BRIDGEBORO ST
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:NJ
Practice Address - Zip Code:08075-3201
Practice Address - Country:US
Practice Address - Phone:856-461-0766
Practice Address - Fax:856-461-7095
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2015-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB07242800207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2688905Medicaid
NJ049078Medicare ID - Type Unspecified
NJ2688905Medicaid