Basic Information
| Provider Information | |||||||||
| NPI: | 1639513641 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WEISSENBORN | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | RYAN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 911230 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753911230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9729978000 | ||||||||
| FaxNumber: | 9722342987 | ||||||||
| Practice Location | |||||||||
| Address1: | 4450 SOJOURN DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | ADDISON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750015000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9727330014 | ||||||||
| FaxNumber: | 9727330125 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2013 | ||||||||
| LastUpdateDate: | 02/08/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0204X | Q4333 | TX | N | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 390200000X | 574972 | TX | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 2085R0202X | Q4333 | TX | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 398449405 | 05 | TX | MEDICAID |