Provider Demographics
NPI:1548244247
Name:WILSON, MATTHEW (MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:
Last Name:WILSON
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:PO BOX 892649
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92589-2649
Mailing Address - Country:US
Mailing Address - Phone:310-498-1758
Mailing Address - Fax:
Practice Address - Street 1:29645 RANCHO CALIFORNIA RD
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92591-6200
Practice Address - Country:US
Practice Address - Phone:310-498-1758
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-06
Last Update Date:2017-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA53944174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG09354Medicare UPIN