Basic Information
| Provider Information | |||||||||
| NPI: | 1295116721 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLEDSOE | ||||||||
| FirstName: | MATTHEW | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4500 S GARNETT RD STE 112 | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741465201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9189353550 | ||||||||
| FaxNumber: | 9189353581 | ||||||||
| Practice Location | |||||||||
| Address1: | 4500 S GARNETT RD STE 112 | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741465201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9189353550 | ||||||||
| FaxNumber: | 9189353581 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2015 | ||||||||
| LastUpdateDate: | 07/30/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 2085R0202X | 38165 | OK | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 207R00000X | 2015017892 | MO | N | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.