Provider Demographics
NPI:1891726295
Name:WILSON, MATTHEW C (MD)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:C
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 1:1001 20TH ST
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25703
Mailing Address - Country:US
Mailing Address - Phone:304-529-6100
Mailing Address - Fax:304-529-0229
Practice Address - Street 1:1001 20TH ST
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25703
Practice Address - Country:US
Practice Address - Phone:304-529-6100
Practice Address - Fax:304-529-0229
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2014-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY24827207KA0200X
WV13029207KA0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0070510000Medicaid
KY64694763Medicaid
KY64694763Medicaid
WV0070510000Medicaid
WVWI0513141Medicare ID - Type Unspecified