Provider Demographics
NPI:1609608280
Name:DAVIDSON, MATTHEW SHANE (PEER SPECIALIST)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:SHANE
Last Name:DAVIDSON
Suffix:
Gender:M
Credentials:PEER SPECIALIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 580
Mailing Address - Street 2:
Mailing Address - City:OKMULGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74447-0580
Mailing Address - Country:US
Mailing Address - Phone:918-549-2643
Mailing Address - Fax:
Practice Address - Street 1:1006 BEAR LANE
Practice Address - Street 2:
Practice Address - City:OKMULGEE
Practice Address - State:OK
Practice Address - Zip Code:74447
Practice Address - Country:US
Practice Address - Phone:918-549-2643
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-14
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist