Healthcare Provider Details

I. General information

NPI: 1891726295
Provider Name (Legal Business Name): MATTHEW C WILSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 09/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 20TH ST
HUNTINGTON WV
25703
US

IV. Provider business mailing address

1001 20TH ST
HUNTINGTON WV
25703
US

V. Phone/Fax

Practice location:
  • Phone: 304-529-6100
  • Fax: 304-529-0229
Mailing address:
  • Phone: 304-529-6100
  • Fax: 304-529-0229

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License Number24827
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License Number13029
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: