Provider Demographics
NPI:1235166703
Name:WISE, JAMES N (MD)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:N
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:PO BOX 1029
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72702-1029
Mailing Address - Country:US
Mailing Address - Phone:918-392-1706
Mailing Address - Fax:918-664-6120
Practice Address - Street 1:4301 W MARKHAM ST # 783
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-7101
Practice Address - Country:US
Practice Address - Phone:501-686-8000
Practice Address - Fax:501-526-5148
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2018-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE44982085R0202X, 2085B0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR157994001Medicaid
ARP00231104OtherRAILROAD MEDICARE
ARP00231104OtherRAILROAD MEDICARE
AR5N265Medicare ID - Type Unspecified
ARI24213Medicare UPIN