Provider Demographics
NPI:1992125355
Name:WISE, JOHNATHAN LLOYD (MD)
Entity type:Individual
Prefix:
First Name:JOHNATHAN
Middle Name:LLOYD
Last Name:WISE
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 1:406 N ACADIA RD
Mailing Address - Street 2:
Mailing Address - City:THIBODAUX
Mailing Address - State:LA
Mailing Address - Zip Code:70301-4856
Mailing Address - Country:US
Mailing Address - Phone:985-446-2890
Mailing Address - Fax:985-446-2189
Practice Address - Street 1:406 N ACADIA RD
Practice Address - Street 2:
Practice Address - City:THIBODAUX
Practice Address - State:LA
Practice Address - Zip Code:70301-4856
Practice Address - Country:US
Practice Address - Phone:985-446-2890
Practice Address - Fax:985-446-2189
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-23
Last Update Date:2018-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
LAMD.308148207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program