Provider Demographics
NPI:1487882270
Name:WISE, EMILY MICHELLE (MD)
Entity type:Individual
Prefix:DR
First Name:EMILY
Middle Name:MICHELLE
Last Name:WISE
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 1:20 WILLIAM ST STE G15
Mailing Address - Street 2:
Mailing Address - City:WELLESLEY
Mailing Address - State:MA
Mailing Address - Zip Code:02481-4102
Mailing Address - Country:US
Mailing Address - Phone:781-591-4234
Mailing Address - Fax:781-369-9737
Practice Address - Street 1:20 WILLIAM ST STE G15
Practice Address - Street 2:
Practice Address - City:WELLESLEY
Practice Address - State:MA
Practice Address - Zip Code:02481-4102
Practice Address - Country:US
Practice Address - Phone:781-591-4234
Practice Address - Fax:781-369-9737
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-30
Last Update Date:2019-01-08
Deactivation Date:2019-01-03
Deactivation Code:
Reactivation Date:2019-01-08
Provider Licenses
StateLicense IDTaxonomies
MA254256207NS0135X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1487882270OtherNPI