Provider Demographics
NPI:1235107038
Name:WISE, MATTHEW JAY (MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:JAY
Last Name:WISE
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 1:431 S BATAVIA ST STE 101
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-3937
Mailing Address - Country:US
Mailing Address - Phone:714-363-3300
Mailing Address - Fax:714-363-3847
Practice Address - Street 1:431 S BATAVIA ST STE 101
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-3937
Practice Address - Country:US
Practice Address - Phone:714-363-3300
Practice Address - Fax:714-363-3847
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-09
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC55031202K00000X, 207V00000X, 202K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes202K00000XAllopathic & Osteopathic PhysiciansPhlebology
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM69422834Medicaid
101235Medicare UPIN
NM69422834Medicaid
NM69422834Medicaid