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NPI Code Detail

MEDICARE: MATTHEW W. WISE DO

MEDICARE: MATTHEW W. WISE DO
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207QS0010XSports Medicine (Family Medicine) Physician12803890-1204UT
2207Q00000XFamily Medicine Physician12803890-1204UT

General Provider Information

NPI Number : 1295394161
Entity Type Code : Individual
Provider Name (Legal Business Name) : MATTHEW W. WISE DO
Provider Business Mailing Address
First Line : 590 S WAKARA WAY
Second Line :
City : SALT LAKE CITY
State : UT
Zip : 84108-1200
Country : US
Telephone Number : 801-587-5458
Fax Number :
Provider Business Practice Location Address
First Line : 6201 HARRY HINES BLVD
Second Line :
City : DALLAS
State : TX
Zip : 75390-9201
Country : US
Telephone Number : 214-645-9729
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/13/2019
Last Update Date : 04/08/2024

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Directions to “ MATTHEW W. WISE DO” Practice Location

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