Provider Demographics
NPI:1518938380
Name:GULLICKSON, MATTHEW ALAN (MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:ALAN
Last Name:GULLICKSON
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 1:4601 PARK RD
Mailing Address - Street 2:STE 300
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28209-3239
Mailing Address - Country:US
Mailing Address - Phone:704-323-2000
Mailing Address - Fax:
Practice Address - Street 1:710 PARK CENTER DR
Practice Address - Street 2:STE 300
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28105-5012
Practice Address - Country:US
Practice Address - Phone:704-323-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC27820207X00000X
NC2006-01940207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC278202Medicaid
NC5905641Medicaid
NC0397730030Medicare NSC
H72364Medicare UPIN
NC5905641Medicaid
SC278202Medicaid