Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208200000X | Surgeon | 036150881 | IL |
Y | 208600000X | Surgeon | 036150881 | IL |
NPI | 1003137803 |
---|---|
Provider Name | Douglas Wiseman |
First Address | Chicago, IL 60631-3715 |
Second Address | Chicago, IL 60631-3715 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/06/2010 |
Last Update Date | 28/10/2019 |