Healthcare Provider Details

I. General information

NPI: 1417307059
Provider Name (Legal Business Name): MATTHEW TYLER GRANT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2016
Last Update Date: 08/13/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 CHILDRENS AVE
OKLAHOMA CITY OK
73104-4637
US

IV. Provider business mailing address

1200 CHILDRENS AVE
OKLAHOMA CITY OK
73104-4637
US

V. Phone/Fax

Practice location:
  • Phone: 405-271-3677
  • Fax:
Mailing address:
  • Phone: 402-271-3677
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License Number2018015583
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number2018015583
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: