Provider Demographics
NPI:1760987036
Name:WILDE, MATTHEW (MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:
Last Name:WILDE
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 1:2727 GRAMERCY ST STE 200
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77025-1716
Mailing Address - Country:US
Mailing Address - Phone:713-799-9975
Mailing Address - Fax:713-799-1095
Practice Address - Street 1:2727 GRAMERCY ST STE 200
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77025-1716
Practice Address - Country:US
Practice Address - Phone:713-799-9975
Practice Address - Fax:713-799-1095
Is Sole Proprietor?:No
Enumeration Date:2018-03-28
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXT6080207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program