Provider Demographics
NPI:1063206944
Name:WILSON, MATTHEW JOHN
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JOHN
Last Name:WILSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 CATALPA RD
Mailing Address - Street 2:
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06340-2512
Mailing Address - Country:US
Mailing Address - Phone:207-406-1147
Mailing Address - Fax:
Practice Address - Street 1:103 CATALPA RD
Practice Address - Street 2:
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06340-2512
Practice Address - Country:US
Practice Address - Phone:207-406-1147
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-07
Last Update Date:2025-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman