Provider Demographics
NPI:1871766600
Name:WISEMAN, RICHARD CULWELL (MD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:CULWELL
Last Name:WISEMAN
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 3390
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3390
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1151 MAY ST
Practice Address - Street 2:
Practice Address - City:HOOD RIVER
Practice Address - State:OR
Practice Address - Zip Code:97031-1526
Practice Address - Country:US
Practice Address - Phone:541-387-8992
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-13
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAML60093926208600000X
ORMD168558208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500672454Medicaid
OR500672454Medicaid