Provider Demographics
NPI:1063674190
Name:WISNIEWSKI, PAUL JOHN (DO)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:JOHN
Last Name:WISNIEWSKI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 670
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-0221
Mailing Address - Country:US
Mailing Address - Phone:909-580-3353
Mailing Address - Fax:909-580-1363
Practice Address - Street 1:18523 CORWIN RD STE A
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92307-2300
Practice Address - Country:US
Practice Address - Phone:909-353-5285
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-30
Last Update Date:2025-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA2090622086S0102X
FLOS 120232086S0102X
CA20A9062208600000X
DCDO0347742086S0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
No208600000XAllopathic & Osteopathic PhysiciansSurgery