Provider Demographics
NPI:1528552031
Name:WOLTER, MATTHEW JAMES
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JAMES
Last Name:WOLTER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3145 S FALLING BROOK LN
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-5205
Mailing Address - Country:US
Mailing Address - Phone:208-631-6426
Mailing Address - Fax:
Practice Address - Street 1:3145 S FALLING BROOK LN
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-5205
Practice Address - Country:US
Practice Address - Phone:208-631-6426
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-18
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMRO1909207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine