Provider Demographics
NPI:1427105394
Name:WISE, MARSHALL T (MD)
Entity type:Individual
Prefix:
First Name:MARSHALL
Middle Name:T
Last Name:WISE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 603725
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-3725
Mailing Address - Country:US
Mailing Address - Phone:828-575-2625
Mailing Address - Fax:828-350-2174
Practice Address - Street 1:1606 US HIGHWAY 27 N
Practice Address - Street 2:
Practice Address - City:CYNTHIANA
Practice Address - State:KY
Practice Address - Zip Code:41031-3718
Practice Address - Country:US
Practice Address - Phone:859-234-8852
Practice Address - Fax:859-234-8859
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.099667207K00000X
KY41014207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100021390Medicaid
KYK050922OtherMEDICARE PTAN
OH0089205Medicaid
KYK050921OtherMEDICARE PTAN