Provider Demographics
NPI:1699710467
Name:JERRY A WISHIK, M.D., P.A.
Entity type:Organization
Organization Name:JERRY A WISHIK, M.D., P.A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:A
Authorized Official - Last Name:WISHIK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-684-1777
Mailing Address - Street 1:620 VONDERBURG DR
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-5971
Mailing Address - Country:US
Mailing Address - Phone:813-684-1777
Mailing Address - Fax:813-689-9559
Practice Address - Street 1:620 VONDERBURG DR
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5971
Practice Address - Country:US
Practice Address - Phone:813-684-1777
Practice Address - Fax:813-689-9559
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD58825Medicare UPIN
FL79597Medicare ID - Type Unspecified