Provider Demographics
NPI:1447305636
Name:WISHIK, JEFFREY (MD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:WISHIK
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 1:1 RANDALL SQ
Mailing Address - Street 2:SUITE 409
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02904-2709
Mailing Address - Country:US
Mailing Address - Phone:401-274-5150
Mailing Address - Fax:401-274-5130
Practice Address - Street 1:1 RANDALL SQ
Practice Address - Street 2:SUITE 409
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02904-2709
Practice Address - Country:US
Practice Address - Phone:401-274-5150
Practice Address - Fax:401-274-5130
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD071602084N0400X, 2084N0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI9000115Medicaid
RI9000115Medicaid