Provider Demographics
NPI:1053337121
Name:SUSAN B. WISE, O.D., P.A.
Entity type:Organization
Organization Name:SUSAN B. WISE, O.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WISE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:828-689-4206
Mailing Address - Street 1:PO BOX 850
Mailing Address - Street 2:
Mailing Address - City:MARS HILL
Mailing Address - State:NC
Mailing Address - Zip Code:28754-0850
Mailing Address - Country:US
Mailing Address - Phone:828-689-4206
Mailing Address - Fax:828-689-5007
Practice Address - Street 1:63 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:MARS HILL
Practice Address - State:NC
Practice Address - Zip Code:28754-7542
Practice Address - Country:US
Practice Address - Phone:828-689-4206
Practice Address - Fax:828-689-5007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-14
Last Update Date:2009-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1053337121OtherGROUP NPI
NC0261NOtherBCBSNC
NC5900858Medicaid
NCDE9589OtherRAILROAD MEDICARE
NCDE9589OtherRAILROAD MEDICARE
NC2471762Medicare ID - Type Unspecified