Provider Demographics
NPI:1184222309
Name:MATTHEWS, JAMES GLENN
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:GLENN
Last Name:MATTHEWS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 W WALLACE DR
Mailing Address - Street 2:
Mailing Address - City:ENID
Mailing Address - State:OK
Mailing Address - Zip Code:73703-7912
Mailing Address - Country:US
Mailing Address - Phone:580-231-8915
Mailing Address - Fax:
Practice Address - Street 1:1824 S VAN BUREN ST
Practice Address - Street 2:
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73703-7903
Practice Address - Country:US
Practice Address - Phone:405-230-1181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-09
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1215150644175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKV083161617OtherDRIVER ID