Provider Demographics
NPI:1225030562
Name:ROBERTS, MATTHEW HAROLD (DPM)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:HAROLD
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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 102
Practice Address - City:MIAMI
Practice Address - State:OK
Practice Address - Zip Code:74354-6708
Practice Address - Country:US
Practice Address - Phone:918-540-7655
Practice Address - Fax:918-540-7668
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-01
Last Update Date:2012-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK223213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100780830AMedicaid
OK1225030562Medicare Oscar/Certification
OK249719406Medicare PIN
OK100780830AMedicaid