Provider Demographics
NPI:1780632273
Name:MATOS, RANDALL JOSEPH (DPM)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:JOSEPH
Last Name:MATOS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 400
Mailing Address - Street 2:
Mailing Address - City:POTEAU
Mailing Address - State:OK
Mailing Address - Zip Code:74953-0400
Mailing Address - Country:US
Mailing Address - Phone:918-649-3777
Mailing Address - Fax:918-649-3891
Practice Address - Street 1:1103 DEWEY AVE
Practice Address - Street 2:
Practice Address - City:POTEAU
Practice Address - State:OK
Practice Address - Zip Code:74953-4411
Practice Address - Country:US
Practice Address - Phone:918-649-3777
Practice Address - Fax:918-649-3891
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2011-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK193213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100779740AMedicaid
OK100779740AMedicaid
OK$$$$$$$$$RMedicare PIN