Provider Demographics
NPI:1700363868
Name:MATHENY, JOHN WILLIAM
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:WILLIAM
Last Name:MATHENY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2416 NEZ PERCE TRL
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73003-1178
Mailing Address - Country:US
Mailing Address - Phone:405-938-5353
Mailing Address - Fax:
Practice Address - Street 1:2416 NEZ PERCE TRL
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73003-1178
Practice Address - Country:US
Practice Address - Phone:405-938-5353
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-22
Last Update Date:2018-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator