Provider Demographics
NPI:1699717975
Name:WISDA, CATHERINE L (MD)
Entity type:Individual
Prefix:
First Name:CATHERINE
Middle Name:L
Last Name:WISDA
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 1:1318 S MAIN RD
Mailing Address - Street 2:BLDG. 2A
Mailing Address - City:VINELAND
Mailing Address - State:NJ
Mailing Address - Zip Code:08360-6516
Mailing Address - Country:US
Mailing Address - Phone:856-692-8008
Mailing Address - Fax:856-692-8044
Practice Address - Street 1:1318 S MAIN RD
Practice Address - Street 2:BLDG. 2A
Practice Address - City:VINELAND
Practice Address - State:NJ
Practice Address - Zip Code:08360-6516
Practice Address - Country:US
Practice Address - Phone:856-692-8008
Practice Address - Fax:856-692-8044
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2010-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05025100207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7014007Medicaid
NJE53674Medicare UPIN
NJ7014007Medicaid