Provider Demographics
NPI:1457346215
Name:WAKELEY, MATTHEW A (DO)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:A
Last Name:WAKELEY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:604 APPLE DR
Mailing Address - Street 2:
Mailing Address - City:MULLICA HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08062-9476
Mailing Address - Country:US
Mailing Address - Phone:609-501-4040
Mailing Address - Fax:
Practice Address - Street 1:1 MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:PA
Practice Address - Zip Code:19013
Practice Address - Country:US
Practice Address - Phone:609-501-4040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-16
Last Update Date:2009-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB07749100207P00000X
PAOS-010326-L207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0048038Medicaid
NJ084347Medicare ID - Type Unspecified
NJ0048038Medicaid