Provider Demographics
NPI:1588130496
Name:WISE, CHARLOTTE MARIE (MD)
Entity type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:MARIE
Last Name:WISE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 SOUTHFORK VILLAGE DR APT 101
Mailing Address - Street 2:
Mailing Address - City:BELMONT
Mailing Address - State:NC
Mailing Address - Zip Code:28012-7823
Mailing Address - Country:US
Mailing Address - Phone:704-674-5055
Mailing Address - Fax:
Practice Address - Street 1:1000 SOUTHFORK VILLAGE DR APT 101
Practice Address - Street 2:
Practice Address - City:BELMONT
Practice Address - State:NC
Practice Address - Zip Code:28012-7823
Practice Address - Country:US
Practice Address - Phone:704-674-5055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-17
Last Update Date:2018-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC34904207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology