Provider Demographics
NPI:1528175882
Name:WISEMAN, MERRELL THAMES (MD)
Entity type:Individual
Prefix:DR
First Name:MERRELL
Middle Name:THAMES
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 1:1810 34TH AVE
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98122-3342
Mailing Address - Country:US
Mailing Address - Phone:206-323-3765
Mailing Address - Fax:
Practice Address - Street 1:4800 SAND POINT WAY NE
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98105-3901
Practice Address - Country:US
Practice Address - Phone:206-987-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2009-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00025137208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAWI7556OtherBLUE SHIELD VM
WA8108789Medicaid
WAUS4590191OtherAETNA SPECIALIST PIN
WAG8880842Medicare PIN
WA0135758Medicare ID - Type Unspecified
WA8108789Medicaid
WAG000135758Medicare PIN