Provider Demographics
NPI:1831741321
Name:WISHNOFF, MATTHEW S
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:S
Last Name:WISHNOFF
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 N LARRABEE ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60610-1119
Mailing Address - Country:US
Mailing Address - Phone:312-330-1861
Mailing Address - Fax:
Practice Address - Street 1:1201 E MARSHALL ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23298-5026
Practice Address - Country:US
Practice Address - Phone:804-828-9788
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-15
Last Update Date:2019-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program