Provider Demographics
NPI:1467428540
Name:WILLIAMSON, MATTHEW E (DO)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:E
Last Name:WILLIAMSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2265 E SUNNYSIDE RD
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7598
Mailing Address - Country:US
Mailing Address - Phone:208-542-5000
Mailing Address - Fax:208-542-5151
Practice Address - Street 1:777 HOSPITAL WAY
Practice Address - Street 2:BLDG B
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-5175
Practice Address - Country:US
Practice Address - Phone:208-239-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01022065462085R0202X
IDO-3342085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807225800Medicaid
G92187Medicare UPIN
ID807225800Medicaid
ID1129993Medicare PIN