Provider Demographics
NPI:1699138891
Name:WILSON, MATTHEW D (DPM)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:D
Last Name:WILSON
Suffix:
Gender:
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5555 RESERVOIR DR STE 104
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92120-5198
Mailing Address - Country:US
Mailing Address - Phone:619-286-9480
Mailing Address - Fax:619-286-4568
Practice Address - Street 1:5555 RESERVOIR DR STE 104
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120-5198
Practice Address - Country:US
Practice Address - Phone:619-286-9480
Practice Address - Fax:619-286-4568
Is Sole Proprietor?:No
Enumeration Date:2016-04-04
Last Update Date:2025-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ00000213ES0103X
OH390200000X
CAE5700213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty