Provider Demographics
NPI:1730165234
Name:WISEMAN, RICHARD A (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:A
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 1:140 HOSPITAL DR STE 108
Mailing Address - Street 2:
Mailing Address - City:BENNINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05201-5010
Mailing Address - Country:US
Mailing Address - Phone:802-447-5519
Mailing Address - Fax:802-447-5657
Practice Address - Street 1:140 HOSPITAL DR STE 108
Practice Address - Street 2:
Practice Address - City:BENNINGTON
Practice Address - State:VT
Practice Address - Zip Code:05201-5010
Practice Address - Country:US
Practice Address - Phone:024-447-5519
Practice Address - Fax:802-447-5657
Is Sole Proprietor?:No
Enumeration Date:2005-12-16
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042-0012245207R00000X
MA159649207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3195228Medicaid
VT1006998Medicaid
G95451Medicare UPIN
MA3195228Medicaid