Provider Demographics
NPI:1184892531
Name:WILSON, MATTHEW J (LMT)
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:J
Last Name:WILSON
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 BEAL PKWY SE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32548-5386
Mailing Address - Country:US
Mailing Address - Phone:850-598-3633
Mailing Address - Fax:
Practice Address - Street 1:119 BEAL PKWY SE
Practice Address - Street 2:SUITE 101
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32548-5386
Practice Address - Country:US
Practice Address - Phone:850-598-3633
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-19
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA33164247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLC2463OtherBLUE CROSS & BLUE SHIELD