Basic Information
| Provider Information | |||||||||
| NPI: | 1790884781 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALTERS | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | B. | ||||||||
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| Credential: | P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4401 W MEMORIAL RD | ||||||||
| Address2: | SUITE #141; ATTN: TERRI | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731341785 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4059365800 | ||||||||
| FaxNumber: | 4059365211 | ||||||||
| Practice Location | |||||||||
| Address1: | 4300 W MEMORIAL RD | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731208304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4053147356 | ||||||||
| FaxNumber: | 4053413795 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2006 | ||||||||
| LastUpdateDate: | 05/19/2008 | ||||||||
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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 | 3560 | OK | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 3560 | 01 | OK | PT LICENSE | OTHER |