Provider Demographics
NPI:1093759755
Name:WISS, JOAN M (MD)
Entity type:Individual
Prefix:DR
First Name:JOAN
Middle Name:M
Last Name:WISS
Suffix:
Gender:
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:PO BOX 70157
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29572-0021
Mailing Address - Country:US
Mailing Address - Phone:843-504-2121
Mailing Address - Fax:843-487-0123
Practice Address - Street 1:506 2ND AVE N
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577-3922
Practice Address - Country:US
Practice Address - Phone:843-796-7422
Practice Address - Fax:877-817-3832
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC18560207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC185604Medicaid
SC185604Medicaid