1043399900 NPI number — DR. STANLEY WALTER WISNIOSKI III D.O.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043399900 NPI number — DR. STANLEY WALTER WISNIOSKI III D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WISNIOSKI
Provider First Name:
STANLEY
Provider Middle Name:
WALTER
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
III
Provider Credential Text:
D.O.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1043399900
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/16/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10887 N MILITARY TRL STE 5
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PALM BEACH GARDENS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33410-6528
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-324-9600
Provider Business Mailing Address Fax Number:
561-779-9980

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10887 N MILITARY TRL STE 5
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PALM BEACH GARDENS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33410-6528
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-324-9600
Provider Business Practice Location Address Fax Number:
561-799-9980
Provider Enumeration Date:
11/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  OS9152 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 204D00000X , with the licence number: OS9152 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 52028 . This is a "BLUE CROSS BLUE SHIELD ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: K6281 . This is a "MEDICARE GROUP ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: U3317Z . This is a "MEDICARE SIFFIX" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: OS9152 . This is a "MEDICAL LICENSE NUMBER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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