Provider Demographics
NPI:1437221694
Name:DRAELOS, MATTHEW THEODORE (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:THEODORE
Last Name:DRAELOS
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 1:200 N BRYANT AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73034-6273
Mailing Address - Country:US
Mailing Address - Phone:405-330-2362
Mailing Address - Fax:405-330-2363
Practice Address - Street 1:200 N BRYANT AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73034-6273
Practice Address - Country:US
Practice Address - Phone:405-330-2362
Practice Address - Fax:405-330-2363
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2008-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK15748207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKOK401293OtherMEDICARE TPAN
E27635Medicare UPIN