Provider Demographics
NPI:1255487393
Name:GRANTHAM, MATT L (OD)
Entity Type:Individual
Prefix:DR
First Name:MATT
Middle Name:L
Last Name:GRANTHAM
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:218 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WILBURTON
Mailing Address - State:OK
Mailing Address - Zip Code:74578-4046
Mailing Address - Country:US
Mailing Address - Phone:918-465-3780
Mailing Address - Fax:918-465-3313
Practice Address - Street 1:218 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WILBURTON
Practice Address - State:OK
Practice Address - Zip Code:74578-4046
Practice Address - Country:US
Practice Address - Phone:918-465-3780
Practice Address - Fax:918-465-3313
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2009-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKXXXX152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200090590AMedicaid
OK100851340AMedicaid
OK100851340BMedicaid
OK200090590BMedicaid
OK100851340BMedicaid
OK200090590BMedicaid
OK100851340AMedicaid
OK4976380001Medicare NSC
OK248302403Medicare PIN
OK800522182Medicare PIN
248302402Medicare PIN