Provider Demographics
NPI:1043231178
Name:WISDOM, MATTHEW (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:WISDOM
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 743904
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3904
Mailing Address - Country:US
Mailing Address - Phone:803-296-7320
Mailing Address - Fax:803-296-7330
Practice Address - Street 1:1000 JOHNSON FERRY RD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342
Practice Address - Country:US
Practice Address - Phone:404-851-8146
Practice Address - Fax:404-851-6325
Is Sole Proprietor?:No
Enumeration Date:2006-07-22
Last Update Date:2018-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC25851207R00000X
GA069150208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC258517Medicaid
GA003131332AMedicaid
SCBW8511948OtherCONTROLLED SUBSTANCE REGI
SCTL25851OtherLICENSE NUMBER
GA003131332AMedicaid
SCI58732Medicare UPIN
SCTL25851OtherLICENSE NUMBER
SC292864Medicaid
SCSC93967579Medicare PIN
SCSC93965773Medicare PIN