Provider Demographics
NPI:1902163710
Name:WHEALON, MATTHEW D (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:D
Last Name:WHEALON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 670
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-0221
Mailing Address - Country:US
Mailing Address - Phone:909-580-3353
Mailing Address - Fax:909-580-1363
Practice Address - Street 1:400 N. PEPPER AVE.
Practice Address - Street 2:MOB SUITE 308
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-1801
Practice Address - Country:US
Practice Address - Phone:909-580-3353
Practice Address - Fax:909-580-1363
Is Sole Proprietor?:No
Enumeration Date:2012-04-18
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA128935208600000X, 208C00000X
PAMT216910208C00000X
PAMD464833208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery