Provider Demographics
NPI:1104022417
Name:DIESSELHORST, MATTHEW M (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:M
Last Name:DIESSELHORST
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 1:10914 HEFNER POINTE DR STE 200
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73120-5069
Mailing Address - Country:US
Mailing Address - Phone:405-463-3337
Mailing Address - Fax:405-463-3338
Practice Address - Street 1:10914 HEFNER POINTE DR STE 200
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-5069
Practice Address - Country:US
Practice Address - Phone:405-463-3337
Practice Address - Fax:405-463-3338
Is Sole Proprietor?:No
Enumeration Date:2007-06-23
Last Update Date:2020-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK25730207XX0801X, 207XX0005X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0801XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Trauma
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK25730OtherMEDICAL LICENSE