Provider Demographics
NPI:1659514701
Name:WHEATLEY, MATTHEW DEAN (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:DEAN
Last Name:WHEATLEY
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 1:3400 DATA DR
Mailing Address - Street 2:PHYSICIAN SUPPORT SERVICES
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-7956
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6511 COYLE AVE
Practice Address - Street 2:
Practice Address - City:CARMICHAEL
Practice Address - State:CA
Practice Address - Zip Code:95608-0306
Practice Address - Country:US
Practice Address - Phone:916-863-8700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-18
Last Update Date:2014-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA1305922085R0001X, 2085R0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2085R0203XAllopathic & Osteopathic PhysiciansRadiologyTherapeutic Radiology