Provider Demographics
NPI:1336119247
Name:MATHEWS, GARY (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:
Last Name:MATHEWS
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 640
Mailing Address - Street 2:
Mailing Address - City:BEAVER
Mailing Address - State:OK
Mailing Address - Zip Code:73932-0640
Mailing Address - Country:US
Mailing Address - Phone:580-625-3477
Mailing Address - Fax:580-625-3562
Practice Address - Street 1:718 AVENUE A
Practice Address - Street 2:
Practice Address - City:BEAVER
Practice Address - State:OK
Practice Address - Zip Code:73932-3101
Practice Address - Country:US
Practice Address - Phone:580-625-3477
Practice Address - Fax:580-625-3562
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2014-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK24441207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
1124441OtherCHAMPUS
OK200058570AMedicaid
C18941Medicare UPIN