Provider Demographics
NPI:1043873706
Name:WHITTAKER, MATTHEW RAY (DO)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:RAY
Last Name:WHITTAKER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:408 S CHESTNUT AVE
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-3407
Mailing Address - Country:US
Mailing Address - Phone:918-706-1011
Mailing Address - Fax:
Practice Address - Street 1:4401 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73109-3413
Practice Address - Country:US
Practice Address - Phone:405-636-7195
Practice Address - Fax:405-979-8459
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-18
Last Update Date:2020-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK7054207P00000X
OK0335R390200000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program