Provider Demographics
NPI:1982848040
Name:BRESKE, MATTHEW L (SFIDC)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:L
Last Name:BRESKE
Suffix:
Gender:M
Credentials:SFIDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7791 MERCURY RD
Mailing Address - Street 2:FAIRECONRON FOUR
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73145-8712
Mailing Address - Country:US
Mailing Address - Phone:405-734-2914
Mailing Address - Fax:
Practice Address - Street 1:7791 MERCURY RD
Practice Address - Street 2:FAIRECONRON FOUR
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73145-8712
Practice Address - Country:US
Practice Address - Phone:405-582-6615
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-20
Last Update Date:2013-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman