1477637643 NPI number — MATT GRANTHAM, OD, PC

Table of content: (NPI 1477637643)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477637643 NPI number — MATT GRANTHAM, OD, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MATT GRANTHAM, OD, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1477637643
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/06/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
101 SMITH AVE
Provider Second Line Business Mailing Address:
SUITE #2
Provider Business Mailing Address City Name:
POTEAU
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74953-2613
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-647-9283
Provider Business Mailing Address Fax Number:
918-649-0878

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 SMITH AVE
Provider Second Line Business Practice Location Address:
SUITE #2
Provider Business Practice Location Address City Name:
POTEAU
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74953-2613
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-647-9283
Provider Business Practice Location Address Fax Number:
918-649-0878
Provider Enumeration Date:
10/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GRANTHAM
Authorized Official First Name:
DANA
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
918-647-9283

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 100851340B , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200090590B , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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