Individual
LARRY KEITH WISE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Taxonomy
Speciality
Code
Description
License number
State
2084P0800X
Psychiatry Physician
Primary
D0051458
MD
2084P0800X
Psychiatry Physician
MD26174
OR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1225016561
GROUP NPI #
OR
05
—
609550001
—
MD
05
—
609550002
—
MD
05
—
609550004
—
MD
01
—
930593249
GROUP TAX ID #
OR
01
—
LM49EA
CAREFIRST BCBS LOCAL
MD
01
—
R968
CAREFIRST BCBS
MD
Enumeration date
02/23/2007
Last updated
04/28/2011
Update your record
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