Provider Demographics
NPI:1942567672
Name:WILSON, MATTHEW DWAIN (MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:DWAIN
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:2 WHEELER ST
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31405-5700
Mailing Address - Country:US
Mailing Address - Phone:912-353-7744
Mailing Address - Fax:912-355-9124
Practice Address - Street 1:1000 TOWNE CENTER BLVD STE 1000B
Practice Address - Street 2:
Practice Address - City:POOLER
Practice Address - State:GA
Practice Address - Zip Code:31322
Practice Address - Country:US
Practice Address - Phone:912-353-7744
Practice Address - Fax:912-348-3589
Is Sole Proprietor?:No
Enumeration Date:2012-04-19
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA078491208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
203704507OtherTAX ID NUMBER