Provider Demographics
NPI:1790016434
Name:MATIS DERMATOLOGY, PC
Entity Type:Organization
Organization Name:MATIS DERMATOLOGY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DERMATOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:
Authorized Official - Last Name:MATIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-521-0100
Mailing Address - Street 1:PO BOX 9697
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84109-9697
Mailing Address - Country:US
Mailing Address - Phone:801-521-0100
Mailing Address - Fax:801-521-5227
Practice Address - Street 1:710 E 200 S
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-2265
Practice Address - Country:US
Practice Address - Phone:801-521-0100
Practice Address - Fax:801-521-5227
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-20
Last Update Date:2010-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT185450-1205207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT4011956Medicare PIN