Provider Demographics
NPI:1437355112
Name:WISE OPHTHALMOLOGY GROUP, P.A.
Entity type:Organization
Organization Name:WISE OPHTHALMOLOGY GROUP, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:F
Authorized Official - Last Name:WISE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:954-963-4990
Mailing Address - Street 1:3816 HOLLYWOOD BLVD
Mailing Address - Street 2:STE 101
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33021-6750
Mailing Address - Country:US
Mailing Address - Phone:954-963-4990
Mailing Address - Fax:954-963-1848
Practice Address - Street 1:3816 HOLLYWOOD BLVD
Practice Address - Street 2:STE 101
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021-6750
Practice Address - Country:US
Practice Address - Phone:954-963-4990
Practice Address - Fax:954-963-1848
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-21
Last Update Date:2008-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL034543174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL33274Medicare PIN
FL0515660001Medicare NSC