Provider Demographics
NPI:1558387258
Name:DREW, MATTHEW THEODORE (OD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:THEODORE
Last Name:DREW
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111A FORT CAMPBELL BLVD
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37042-6426
Mailing Address - Country:US
Mailing Address - Phone:931-645-0346
Mailing Address - Fax:931-645-0348
Practice Address - Street 1:1111A FORT CAMPBELL BLVD
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37042-6426
Practice Address - Country:US
Practice Address - Phone:931-645-0346
Practice Address - Fax:931-645-0348
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2019-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2519152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY77001485Medicaid
KY77001485Medicaid
TN3946250Medicare ID - Type Unspecified
TN5564960001Medicare NSC