Healthcare Provider Details

I. General information

NPI: 1063306371
Provider Name (Legal Business Name): MATTHEW DAVID WIEFELS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2025
Last Update Date: 06/03/2025
Certification Date: 06/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 STANTON L YOUNG BLVD # 1464
OKLAHOMA CITY OK
73104-5018
US

IV. Provider business mailing address

1916 HERITAGE PARK DR APT 148
OKLAHOMA CITY OK
73120-7547
US

V. Phone/Fax

Practice location:
  • Phone: 405-271-5504
  • Fax:
Mailing address:
  • Phone: 305-992-8522
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License Number45936
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: