Provider Demographics
NPI:1407876246
Name:RANDALL J MATOS DPM PC
Entity Type:Organization
Organization Name:RANDALL J MATOS DPM PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:MATOS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:918-649-3777
Mailing Address - Street 1:PO BOX 400
Mailing Address - Street 2:
Mailing Address - City:POTEAU
Mailing Address - State:OK
Mailing Address - Zip Code:74953-0400
Mailing Address - Country:US
Mailing Address - Phone:918-649-3777
Mailing Address - Fax:918-649-3891
Practice Address - Street 1:1103 DEWEY AVENUE
Practice Address - Street 2:
Practice Address - City:POTEAU
Practice Address - State:OK
Practice Address - Zip Code:74953-4411
Practice Address - Country:US
Practice Address - Phone:918-649-3777
Practice Address - Fax:918-649-3891
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2011-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK193213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKDN2101OtherRAILROAD MEDICARE
OK200199110AMedicaid
OK4407870001Medicare NSC
OK800522044Medicare PIN