Provider Demographics
NPI:1124227483
Name:WIEDUWILT, MATTHEW JOSEPH (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:JOSEPH
Last Name:WIEDUWILT
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:MEDICAL CENTER BLVD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27157-0001
Mailing Address - Country:US
Mailing Address - Phone:336-713-5440
Mailing Address - Fax:336-713-5445
Practice Address - Street 1:MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27157-5418
Practice Address - Country:US
Practice Address - Phone:336-713-5440
Practice Address - Fax:336-713-5445
Is Sole Proprietor?:No
Enumeration Date:2007-07-16
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA99612207R00000X, 207RH0003X
OK38014207RH0003X
NC2022-02762207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine