Provider Demographics
NPI:1043211683
Name:WISE, BRIAN KEITH (MD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:KEITH
Last Name:WISE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6053 S QUEBEC ST STE 203
Mailing Address - Street 2:
Mailing Address - City:CENTENNIAL
Mailing Address - State:CO
Mailing Address - Zip Code:80111-4505
Mailing Address - Country:US
Mailing Address - Phone:720-708-4287
Mailing Address - Fax:720-815-2581
Practice Address - Street 1:6053 S QUEBEC ST STE 203
Practice Address - Street 2:
Practice Address - City:CENTENNIAL
Practice Address - State:CO
Practice Address - Zip Code:80111-4505
Practice Address - Country:US
Practice Address - Phone:720-708-4287
Practice Address - Fax:720-815-2581
Is Sole Proprietor?:No
Enumeration Date:2005-08-04
Last Update Date:2024-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO412872084P0804X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC811544OtherMEDICARE PTAN
CO1043211683OtherNPI NUMBER
CO70583072Medicaid
COC802299OtherMEDICARE
CO1043211683OtherNPI NUMBER