Basic Information
Provider Information | |||||||||
NPI: | 1902163710 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WHEALON | ||||||||
FirstName: | MATTHEW | ||||||||
MiddleName: | D | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 670 | ||||||||
Address2: |   | ||||||||
City: | REDLANDS | ||||||||
State: | CA | ||||||||
PostalCode: | 923730221 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9095803353 | ||||||||
FaxNumber: | 9095801363 | ||||||||
Practice Location | |||||||||
Address1: | 400 N. PEPPER AVE. | ||||||||
Address2: | MOB SUITE 308 | ||||||||
City: | COLTON | ||||||||
State: | CA | ||||||||
PostalCode: | 923241801 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9095803353 | ||||||||
FaxNumber: | 9095801363 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/18/2012 | ||||||||
LastUpdateDate: | 03/10/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/10/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | A128935 | CA | N |   | Allopathic & Osteopathic Physicians | Surgery |   | 208C00000X | MT216910 | PA | N |   | Allopathic & Osteopathic Physicians | Colon & Rectal Surgery |   | 208C00000X | MD464833 | PA | N |   | Allopathic & Osteopathic Physicians | Colon & Rectal Surgery |   | 208C00000X | A128935 | CA | Y |   | Allopathic & Osteopathic Physicians | Colon & Rectal Surgery |   |
No ID Information.