Provider Demographics
NPI:1528040979
Name:WIETRZYKOWSKI, MATTHEW J (MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:J
Last Name:WIETRZYKOWSKI
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:9230 JOSEPH CAMPAU ST
Mailing Address - Street 2:
Mailing Address - City:HAMTRAMCK
Mailing Address - State:MI
Mailing Address - Zip Code:48212-3731
Mailing Address - Country:US
Mailing Address - Phone:313-875-9270
Mailing Address - Fax:313-875-9420
Practice Address - Street 1:9230 JOSEPH CAMPAU ST
Practice Address - Street 2:
Practice Address - City:HAMTRAMCK
Practice Address - State:MI
Practice Address - Zip Code:48212-3731
Practice Address - Country:US
Practice Address - Phone:313-875-9270
Practice Address - Fax:313-875-9420
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-18
Last Update Date:2019-06-14
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI4301063858207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4391529Medicaid
MI5458769OtherAETNA
MI151659OtherGREAT LAKES
MI1528040979Medicaid
MIP00029377OtherRAILROAD MEDICARE
MI022808OtherMIDWEST HEALTH PLAN
MI1108269932OtherBCBS
MIG76852OtherHAP
MIG76852OtherHAP
MI1108269932OtherBCBS
G76852Medicare UPIN