=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497781207
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MATHEW J IVORY M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/23/2006
-----------------------------------------------------
Last Update Date | 04/11/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2004 N HIGHWAY 81
-----------------------------------------------------
City | DUNCAN
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73533-1460
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-255-0500
-----------------------------------------------------
Fax | 580-252-1684
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2004 N HIGHWAY 81
-----------------------------------------------------
City | DUNCAN
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73533-1460
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-255-0500
-----------------------------------------------------
Fax | 580-252-1684
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 20243
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------