Provider Demographics
NPI:1316932882
Name:WISEMAN, JON MARTIN (MD)
Entity type:Individual
Prefix:
First Name:JON
Middle Name:MARTIN
Last Name:WISEMAN
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 1:5410 CONNECTICUT AVE NW
Mailing Address - Street 2:SUITE 117
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20015
Mailing Address - Country:US
Mailing Address - Phone:202-966-8868
Mailing Address - Fax:202-244-3071
Practice Address - Street 1:5410 CONNECTICUT AVE NW
Practice Address - Street 2:SUITE 117
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20015-2859
Practice Address - Country:US
Practice Address - Phone:202-966-8868
Practice Address - Fax:202-244-3071
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2007-10-18
Deactivation Date:2006-03-22
Deactivation Code:
Reactivation Date:2006-09-27
Provider Licenses
StateLicense IDTaxonomies
DC12890207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCC61959Medicare UPIN
DC122543J17Medicare PIN