Provider Demographics
NPI:1477637643
Name:MATT GRANTHAM, OD, PC
Entity Type:Organization
Organization Name:MATT GRANTHAM, OD, PC
Other - Org Name:GRANTHAM EYE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DANA
Authorized Official - Middle Name:M
Authorized Official - Last Name:GRANTHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-647-9283
Mailing Address - Street 1:101 SMITH AVE
Mailing Address - Street 2:SUITE #2
Mailing Address - City:POTEAU
Mailing Address - State:OK
Mailing Address - Zip Code:74953-2613
Mailing Address - Country:US
Mailing Address - Phone:918-647-9283
Mailing Address - Fax:918-649-0878
Practice Address - Street 1:101 SMITH AVE
Practice Address - Street 2:SUITE #2
Practice Address - City:POTEAU
Practice Address - State:OK
Practice Address - Zip Code:74953-2613
Practice Address - Country:US
Practice Address - Phone:918-647-9283
Practice Address - Fax:918-649-0878
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100851340BMedicaid
OK200090590BMedicaid
OK200090590BMedicaid
OK800522183Medicare PIN
OK100851340BMedicaid
OK248302403Medicare PIN