Healthcare Provider Details

I. General information

NPI: 1376830356
Provider Name (Legal Business Name): MATTHEW HALLETT WILEY D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2011
Last Update Date: 01/03/2023
Certification Date: 01/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 MORRIS DR
OKMULGEE OK
74447-6429
US

IV. Provider business mailing address

10614 S NANDINA CT
JENKS OK
74037-2649
US

V. Phone/Fax

Practice location:
  • Phone: 918-758-3177
  • Fax:
Mailing address:
  • Phone: 918-991-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number5055
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: