Provider Demographics
NPI:1407851595
Name:MATIS, WENDY L (MD)
Entity Type:Individual
Prefix:DR
First Name:WENDY
Middle Name:L
Last Name:MATIS
Suffix:
Gender:F
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 9697
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84109-9697
Mailing Address - Country:US
Mailing Address - Phone:801-521-0100
Mailing Address - Fax:
Practice Address - Street 1:710 E 200 S
Practice Address - Street 2:STE 1B
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-2265
Practice Address - Country:US
Practice Address - Phone:801-521-0100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-16
Last Update Date:2016-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT185450-1205207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT0000119565Medicare PIN