Basic Information
| Provider Information | |||||||||
| NPI: | 1679769947 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLACK | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | JOHN | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | MPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 201 N 4TH ST | ||||||||
| Address2: | |||||||||
| City: | WEATHERFORD | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730964636 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 4004 S YALE AVE | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741356017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186224126 | ||||||||
| FaxNumber: | 9182702398 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2007 | ||||||||
| LastUpdateDate: | 06/30/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 4036 | OK | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 200135840A | 05 | OK | MEDICAID |