Provider Demographics
NPI:1487797213
Name:WISE, KATHRYN SOVINE (OD)
Entity type:Individual
Prefix:DR
First Name:KATHRYN
Middle Name:SOVINE
Last Name:WISE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:603 COUNTRY CLUB DR
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43055-2154
Mailing Address - Country:US
Mailing Address - Phone:740-344-1312
Mailing Address - Fax:740-344-1365
Practice Address - Street 1:603 COUNTRY CLUB DR
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055-2154
Practice Address - Country:US
Practice Address - Phone:740-344-1312
Practice Address - Fax:740-344-1365
Is Sole Proprietor?:No
Enumeration Date:2007-02-14
Last Update Date:2010-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH5165152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2269781Medicaid
OH80776Medicare UPIN