MEDICARE: DR. WENDY L MATIS 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	207N00000X	Dermatology Physician	185450-1205	UT

General Provider Information

NPI Number	:	1407851595
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. WENDY L MATIS M.D.

Provider Business Mailing Address
First Line	:	PO BOX 9697
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84109-9697
Country	:	US
Telephone Number	:	801-521-0100
Fax Number	:

Provider Business Practice Location Address
First Line	:	710 E 200 S
Second Line	:	STE 1B
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84102-2265
Country	:	US
Telephone Number	:	801-521-0100
Fax Number	:

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

Provider Enumeration Date	:	06/16/2005
Last Update Date	:	01/25/2016

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