Healthcare Provider Details

I. General information

NPI: 1700566817
Provider Name (Legal Business Name): MATTHEW ENDRES OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/24/2023
Last Update Date: 11/15/2024
Certification Date: 11/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

681 W CHOCTAW ST
TAHLEQUAH OK
74464-3711
US

IV. Provider business mailing address

PO BOX 1613
TAHLEQUAH OK
74465-1613
US

V. Phone/Fax

Practice location:
  • Phone: 918-456-2250
  • Fax: 918-456-2251
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3218
License Number StateOK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: