MEDICARE: DR. MATTHEW RYAN WILSON M.D.

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
1	208C00000X	Colon & Rectal Surgery Physician	ME162821	FL

General Provider Information

NPI Number	:	1316006083
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MATTHEW RYAN WILSON M.D.

Provider Business Mailing Address
First Line	:	PO BOX 947381
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30394-7381
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1185 DUNLAWTON AVE STE 100
Second Line	:
City	:	PORT ORANGE
State	:	FL
Zip	:	32127-2906
Country	:	US
Telephone Number	:	386-756-7066
Fax Number	:	386-671-2820

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/08/2006
Last Update Date	:	10/09/2023

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