Healthcare Provider Details

I. General information

NPI: 1710338728
Provider Name (Legal Business Name): MATTHEW JOHN WILUSZ D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2016
Last Update Date: 05/03/2022
Certification Date: 05/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27351 DEQUINDRE RD
MADISON HEIGHTS MI
48071-3487
US

IV. Provider business mailing address

27351 DEQUINDRE RD
MADISON HEIGHTS MI
48071-3487
US

V. Phone/Fax

Practice location:
  • Phone: 248-967-7795
  • Fax: 248-967-7794
Mailing address:
  • Phone: 248-967-7795
  • Fax: 248-967-7794

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number5101022658
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: