Provider Demographics
NPI:1124498019
Name:MONTELONGO, MATTHEW ALLEN
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:ALLEN
Last Name:MONTELONGO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:608 W HIGHPOINT DR
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:OK
Mailing Address - Zip Code:74075-1530
Mailing Address - Country:US
Mailing Address - Phone:405-743-1968
Mailing Address - Fax:
Practice Address - Street 1:608 W HIGHPOINT DR
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74075-1530
Practice Address - Country:US
Practice Address - Phone:405-743-1968
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-05
Last Update Date:2015-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200255170AMedicaid