Basic Information
| Provider Information | |||||||||
| NPI: | 1316934649 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MATCHETT | ||||||||
| FirstName: | WILMA | ||||||||
| MiddleName: | JEAN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 S UNIVERSITY AVE | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722055302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5016643914 | ||||||||
| FaxNumber: | 5016645246 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 S UNIVERSITY AVE | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722055302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5016643914 | ||||||||
| FaxNumber: | 5016645246 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2005 | ||||||||
| LastUpdateDate: | 12/07/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | C7501 | AR | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0204X | C7501 | AR | N | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
ID Information
| ID | Type | State | Issuer | Description | 123405001 | 05 | AR | MEDICAID |