Individual
DR. DAVID LEO WISE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
115 S 15TH AVE, POCATELLO, ID 83201-4068
(208) 234-0012
(208) 478-7877
Mailing address
115 S 15TH AVE, POCATELLO, ID 83201-4068
(208) 234-0012
(208) 478-7877
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
M-3654
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
3654-1
BLUE CROSS OF IDAHO
ID
Enumeration date
03/06/2007
Last updated
07/09/2007
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