Provider Demographics
NPI:1174839054
Name:WILSON, MATTHEW C (DO)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:C
Last Name:WILSON
Suffix:
Gender:M
Credentials:DO
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Mailing Address - Street 1:SCHNECK PRIMARY CARE - JACKSON PARK
Mailing Address - Street 2:1124 MEDICAL PLACE
Mailing Address - City:SEYMOUR
Mailing Address - State:IN
Mailing Address - Zip Code:47274
Mailing Address - Country:US
Mailing Address - Phone:812-522-1613
Mailing Address - Fax:812-522-6694
Practice Address - Street 1:SCHNECK PRIMARY CARE - JACKSON PARK
Practice Address - Street 2:1124 MEDICAL PLACE
Practice Address - City:SEYMOUR
Practice Address - State:IN
Practice Address - Zip Code:47274
Practice Address - Country:US
Practice Address - Phone:812-522-1613
Practice Address - Fax:812-522-6694
Is Sole Proprietor?:No
Enumeration Date:2010-08-30
Last Update Date:2020-07-09
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IN02005993A207Q00000X
PAOS015755208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine