Provider Demographics
NPI:1679769947
Name:BLACK, MATTHEW JOHN (MPT)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:JOHN
Last Name:BLACK
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 N 4TH ST
Mailing Address - Street 2:
Mailing Address - City:WEATHERFORD
Mailing Address - State:OK
Mailing Address - Zip Code:73096-4636
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4004 S YALE AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-6017
Practice Address - Country:US
Practice Address - Phone:918-622-4126
Practice Address - Fax:918-270-2398
Is Sole Proprietor?:No
Enumeration Date:2007-09-20
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4036225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200135840AMedicaid
OK200135840AMedicaid