Provider Demographics
NPI:1366419434
Name:WISS, BARRY R (DO)
Entity type:Individual
Prefix:DR
First Name:BARRY
Middle Name:R
Last Name:WISS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:3707 N 7TH ST
Mailing Address - Street 2:#305
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85014-5059
Mailing Address - Country:US
Mailing Address - Phone:602-264-9100
Mailing Address - Fax:602-264-9101
Practice Address - Street 1:5823 W EUGIE AVE
Practice Address - Street 2:STE A
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85304-1276
Practice Address - Country:US
Practice Address - Phone:602-843-1265
Practice Address - Fax:602-843-1297
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2008-05-21
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
AZ2029207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ120390OtherGROUP MEDICARE NUMBER
AZ290445-06Medicaid
AZ290445 02Medicaid
AZ317047OtherGROUP MEDICAID NUMBER
AZ290445-06Medicaid
AZ120390OtherGROUP MEDICARE NUMBER
66179Medicare PIN