Provider Demographics
NPI:1316128275
Name:WISBECK, JACOB MICHAEL (MD)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:MICHAEL
Last Name:WISBECK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3333 N CALVERT ST
Mailing Address - Street 2:SUITE 400
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21218-2867
Mailing Address - Country:US
Mailing Address - Phone:410-554-2270
Mailing Address - Fax:
Practice Address - Street 1:3333 N CALVERT ST
Practice Address - Street 2:SUITE 400
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21218-2867
Practice Address - Country:US
Practice Address - Phone:410-554-2270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-20
Last Update Date:2014-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101249076207X00000X
MDD0070654207XX0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAVAA100719Medicare PIN