Provider Demographics
NPI:1295967230
Name:WILKENING, MATTHEW RALPH (OD)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:RALPH
Last Name:WILKENING
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11511 SHADOW CREEK PKWY
Mailing Address - Street 2:
Mailing Address - City:PEARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77584-7298
Mailing Address - Country:US
Mailing Address - Phone:713-442-0000
Mailing Address - Fax:
Practice Address - Street 1:560 MEYERLAND PLAZA MALL
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77096-1615
Practice Address - Country:US
Practice Address - Phone:713-442-3222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-09
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX7520TG152W00000X
CA13777152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX283510001Medicaid
TX283510002Medicaid
TX283510003Medicaid
TX283510003Medicaid
TXTXB133131Medicare PIN