Provider Demographics
NPI:1497781207
Name:IVORY, MATHEW J (MD)
Entity Type:Individual
Prefix:
First Name:MATHEW
Middle Name:J
Last Name:IVORY
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 1:2004 N HIGHWAY 81
Mailing Address - Street 2:
Mailing Address - City:DUNCAN
Mailing Address - State:OK
Mailing Address - Zip Code:73533-1460
Mailing Address - Country:US
Mailing Address - Phone:580-255-0500
Mailing Address - Fax:580-252-1684
Practice Address - Street 1:2004 N HIGHWAY 81
Practice Address - Street 2:
Practice Address - City:DUNCAN
Practice Address - State:OK
Practice Address - Zip Code:73533-1460
Practice Address - Country:US
Practice Address - Phone:580-255-0500
Practice Address - Fax:580-252-1684
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2012-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK20243207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK500522018Medicaid
OKG60983Medicare UPIN
OK500522018Medicaid