Provider Demographics
NPI:1447322326
Name:WISE, JOHN H (OD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:H
Last Name:WISE
Suffix:
Gender:M
Credentials:OD
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 630
Mailing Address - Street 2:
Mailing Address - City:CROWLEY
Mailing Address - State:LA
Mailing Address - Zip Code:70526
Mailing Address - Country:US
Mailing Address - Phone:337-783-1280
Mailing Address - Fax:
Practice Address - Street 1:509 N. AVENUE G
Practice Address - Street 2:
Practice Address - City:CROWLEY
Practice Address - State:LA
Practice Address - Zip Code:70526
Practice Address - Country:US
Practice Address - Phone:337-783-1280
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA812148T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist