Provider Demographics
NPI:1245201136
Name:WOOLLEY, MATTHEW LEON (MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:LEON
Last Name:WOOLLEY
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 1:500 MONTAUK HWY
Mailing Address - Street 2:SUITE U
Mailing Address - City:WEST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11795-4418
Mailing Address - Country:US
Mailing Address - Phone:631-321-0606
Mailing Address - Fax:631-321-1948
Practice Address - Street 1:500 MONTAUK HWY
Practice Address - Street 2:SUITE U
Practice Address - City:WEST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11795-4418
Practice Address - Country:US
Practice Address - Phone:631-321-0606
Practice Address - Fax:631-321-1948
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2011-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY216057174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY216057OtherLICENSE
NY02285707Medicaid
NY3S8941Medicare ID - Type Unspecified
NYH74895Medicare UPIN