Provider Demographics
NPI:1235181579
Name:DEMATTIA, LAURE G (DO)
Entity Type:Individual
Prefix:DR
First Name:LAURE
Middle Name:G
Last Name:DEMATTIA
Suffix:
Gender:F
Credentials:DO
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 1330
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73070-1330
Mailing Address - Country:US
Mailing Address - Phone:405-735-2049
Mailing Address - Fax:405-307-5630
Practice Address - Street 1:2821 36TH AVE NW STE 200
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73072-2477
Practice Address - Country:US
Practice Address - Phone:405-515-2049
Practice Address - Fax:405-307-5630
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2021-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI45995207Q00000X
MN53690207QB0002X
OK5912207QB0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QB0002XAllopathic & Osteopathic PhysiciansFamily MedicineObesity Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
006906261IOtherHUMANA
WI43508500Medicaid
H97640Medicare UPIN
WI010802905Medicare PIN
0019C73601Medicare ID - Type Unspecified
WI004801473Medicare PIN