Provider Demographics
NPI:1124202197
Name:MATTHEW H ROBERTS
Entity Type:Organization
Organization Name:MATTHEW H ROBERTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:H
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:918-540-7655
Mailing Address - Street 1:PO BOX 1323
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:OK
Mailing Address - Zip Code:74355-1323
Mailing Address - Country:US
Mailing Address - Phone:918-540-7655
Mailing Address - Fax:918-540-7668
Practice Address - Street 1:310 2ND AVE SW
Practice Address - Street 2:STE 208
Practice Address - City:MIAMI
Practice Address - State:OK
Practice Address - Zip Code:74354-6702
Practice Address - Country:US
Practice Address - Phone:918-540-7655
Practice Address - Fax:918-540-7668
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-26
Last Update Date:2008-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK223213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK5379090001Medicare NSC
300522145Medicare PIN