Healthcare Provider Details

I. General information

NPI: 1770839979
Provider Name (Legal Business Name): JONATHAN MATTHEW HATLEY O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2012
Last Update Date: 07/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 N OWEN WALTERS BLVD
SALINA OK
74365-5003
US

IV. Provider business mailing address

102 W CLAY RD
TAHLEQUAH OK
74464-8302
US

V. Phone/Fax

Practice location:
  • Phone: 918-434-8516
  • Fax:
Mailing address:
  • Phone: 918-519-4345
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2734
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: