Provider Demographics
NPI:1649896317
Name:AYRES, MATTHEW BOUDREAU (MD)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:BOUDREAU
Last Name:AYRES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:920 STANTON L YOUNG BLVD # WP3150
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73104-5036
Mailing Address - Country:US
Mailing Address - Phone:405-271-6900
Mailing Address - Fax:
Practice Address - Street 1:920 STANTON L YOUNG BLVD # WP3150
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73104-5036
Practice Address - Country:US
Practice Address - Phone:405-271-6900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-18
Last Update Date:2020-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK35938208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology