Provider Demographics
NPI:1316961675
Name:WISNIEWSKI, CAROL ANN (DPM)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:ANN
Last Name:WISNIEWSKI
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:521 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:IL
Mailing Address - Zip Code:61032-5051
Mailing Address - Country:US
Mailing Address - Phone:815-233-0211
Mailing Address - Fax:815-233-0214
Practice Address - Street 1:521 W MAIN ST
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:IL
Practice Address - Zip Code:61032-5051
Practice Address - Country:US
Practice Address - Phone:815-233-0211
Practice Address - Fax:815-233-0214
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILT35589Medicare UPIN
ILNBR249670Medicare ID - Type Unspecified