Provider Demographics
NPI:1245284785
Name:WILNER, MATTHEW L (MD)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:L
Last Name:WILNER
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 1:3600 GASTON AVE
Mailing Address - Street 2:SUITE 1205
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75246-1800
Mailing Address - Country:US
Mailing Address - Phone:214-692-8262
Mailing Address - Fax:214-696-4190
Practice Address - Street 1:8230 WALNUT HILL LN
Practice Address - Street 2:SUITE 700
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-4482
Practice Address - Country:US
Practice Address - Phone:214-691-1902
Practice Address - Fax:214-987-1845
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2017-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH8893208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
80404XOtherBCBS PROVIDER ID
TX340016197OtherRRMCR
TX103838201Medicaid
E48489Medicare UPIN
TX8B5942Medicare PIN
80404XOtherBCBS PROVIDER ID