Provider Demographics
NPI:1194799262
Name:WISE, BRENT R (MD)
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:R
Last Name:WISE
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:PO BOX 194
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10156-0194
Mailing Address - Country:US
Mailing Address - Phone:212-858-9646
Mailing Address - Fax:646-661-1793
Practice Address - Street 1:314 E 30TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-8303
Practice Address - Country:US
Practice Address - Phone:212-858-9646
Practice Address - Fax:646-661-1793
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2014-03-18
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY199091-1207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYG67052Medicare UPIN