Provider Demographics
NPI:1023315090
Name:DEWILD, MATTHEW B (RN, LMT)
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:B
Last Name:DEWILD
Suffix:
Gender:M
Credentials:RN, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:736 FEDERAL ST APT 1205
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52803-5751
Mailing Address - Country:US
Mailing Address - Phone:563-940-1299
Mailing Address - Fax:
Practice Address - Street 1:1020 LINCOLN RD
Practice Address - Street 2:
Practice Address - City:BETTENDORF
Practice Address - State:IA
Practice Address - Zip Code:52722-4141
Practice Address - Country:US
Practice Address - Phone:563-484-0550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-27
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA090478163W00000X, 163WX0106X, 163WI0500X
IA006683225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WI0500XNursing Service ProvidersRegistered NurseInfusion Therapy
No163W00000XNursing Service ProvidersRegistered Nurse
No163WX0106XNursing Service ProvidersRegistered NurseOccupational Health
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist