Provider Demographics
NPI:1760473995
Name:TUCKER, MATTHEW DEAN (DO)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:DEAN
Last Name:TUCKER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1717 S UTICA AVE STE A
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-5346
Mailing Address - Country:US
Mailing Address - Phone:918-748-7557
Mailing Address - Fax:918-403-0383
Practice Address - Street 1:1717 S UTICA AVE STE A
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-5346
Practice Address - Country:US
Practice Address - Phone:918-748-7557
Practice Address - Fax:918-403-0383
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-05
Last Update Date:2020-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3498207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100119850AMedicaid
OK930087699OtherRAILROAD MEDICARE
OK100119850AMedicaid