Basic Information
| Provider Information | |||||||||
| NPI: | 1184617367 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MATHEWS | ||||||||
| FirstName: | DENNIS | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 825 RIDGE LAKE BLVD | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381209411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9016852200 | ||||||||
| FaxNumber: | 9018202342 | ||||||||
| Practice Location | |||||||||
| Address1: | 825 RIDGE LAKE BLVD | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381209411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9016852200 | ||||||||
| FaxNumber: | 9018202342 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2005 | ||||||||
| LastUpdateDate: | 03/15/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 675 | MS | N | Eye and Vision Services Providers | Optometrist | 152W00000X | 1000 | TN | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 675 | 01 | MS | OD LICENSE | OTHER | 410022830 | 01 | TN | RR MEDICARE | OTHER | 111234722 | 05 | AR | MEDICAID | 3124319 | 01 | TN | BCBSTN | OTHER | MM0008676 | 01 | DEA | OTHER | 1000 | 01 | TN | OD LICENSE | OTHER | P01120062 | 01 | MS | RR MEDICARE | OTHER | 00087009 | 05 | MS | MEDICAID | 3595763 | 05 | TN | MEDICAID | 316826809 | 05 | MO | MEDICAID |