Provider Demographics
NPI:1619124286
Name:WILLARD, MATTHEW DIRK (DC)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:DIRK
Last Name:WILLARD
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 VINEGAR HILL RD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27104-5069
Mailing Address - Country:US
Mailing Address - Phone:336-448-1894
Mailing Address - Fax:336-448-1895
Practice Address - Street 1:141 VINEGAR HILL ROAD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27104
Practice Address - Country:US
Practice Address - Phone:336-448-1894
Practice Address - Fax:336-448-1895
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-26
Last Update Date:2013-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3904111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2456085OtherMEDICARE PTAN
111N00000XOtherTAXONOMY
NC086CJOtherBLUE CROSS PTAN
NC5950449Medicaid
NC2451497BOtherMEDICARE GROUP PTAN