Provider Demographics
NPI:1225096050
Name:MATTHEWS, O L (MD)
Entity Type:Individual
Prefix:DR
First Name:O
Middle Name:L
Last Name:MATTHEWS
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:PO BOX 250581
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:MI
Mailing Address - Zip Code:48025-0581
Mailing Address - Country:US
Mailing Address - Phone:313-871-3200
Mailing Address - Fax:313-871-2996
Practice Address - Street 1:29201 TELEGRAPH RD STE 400
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-7647
Practice Address - Country:US
Practice Address - Phone:248-949-9888
Practice Address - Fax:248-325-5998
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI207R00000X174400000X
MI4301038649207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI000000001262OtherCAPE MEDICAL
MI0608226582OtherBCBS
MI47040OtherOMINCARE - INKSTER
MI0668200330OtherBCBSM - INKSTER
MI068820033OtherBCBS FEP - INKSTER
MI1805767Medicaid
MI382418536OtherOMNI HEALTH PLAN
MIP9074OtherBLUE CARE NETWORK
MI124114OtherGREAT LAKES HEALTH PLAN
MI505724OtherCARE CHOICES
MI00000001262AOtherCAPE MEDICAL - INKSTER
MI6820033Medicare ID - Type UnspecifiedMEDICARE - INKSTER
MI0668200330OtherBCBSM - INKSTER
MI1805767Medicaid