Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 1223P0106X | Oral and Maxillofacial Pathology | 7269 | WI |
Y | 1223S0112X | Oral and Maxillofacial Surgeon | 7269 | WI |
NPI | 1497098255 |
---|---|
Provider Name | Dr. Matthew James Midtling |
First Address | Brookfield, WI 53045-5089 |
Second Address | Milwaukee, WI 53226 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/03/2013 |
Last Update Date | 03/10/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1497098255 | (05) | WI |