1023315090 NPI number — MR. MATTHEW B DEWILD RN, LMT

Table of content: MR. MATTHEW B DEWILD RN, LMT (NPI 1023315090)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023315090 NPI number — MR. MATTHEW B DEWILD RN, LMT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEWILD
Provider First Name:
MATTHEW
Provider Middle Name:
B
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
RN, LMT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1023315090
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/12/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
736 FEDERAL ST APT 1205
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DAVENPORT
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52803-5751
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
563-940-1299
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1020 LINCOLN RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BETTENDORF
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52722-4141
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
563-484-0550
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/27/2011

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 163W00000X , with the licence number:  090478 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 163WX0106X , with the licence number: 090478 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225700000X , with the licence number: 006683 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 163WI0500X , with the licence number: 090478 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)