Provider Demographics
NPI:1376830356
Name:WILEY, MATTHEW HALLETT (DO)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:HALLETT
Last Name:WILEY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10614 S NANDINA CT
Mailing Address - Street 2:
Mailing Address - City:JENKS
Mailing Address - State:OK
Mailing Address - Zip Code:74037-2649
Mailing Address - Country:US
Mailing Address - Phone:918-991-5000
Mailing Address - Fax:
Practice Address - Street 1:1401 MORRIS DR
Practice Address - Street 2:
Practice Address - City:OKMULGEE
Practice Address - State:OK
Practice Address - Zip Code:74447-6429
Practice Address - Country:US
Practice Address - Phone:918-758-3177
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-29
Last Update Date:2023-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5055207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology