Provider Demographics
NPI:1689608507
Name:WARDEN, MATTHEW RUSSELL (OD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:RUSSELL
Last Name:WARDEN
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 1:519 MASON RD
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-7928
Mailing Address - Country:US
Mailing Address - Phone:931-372-7535
Mailing Address - Fax:
Practice Address - Street 1:589 W MAIN ST
Practice Address - Street 2:
Practice Address - City:ALGOOD
Practice Address - State:TN
Practice Address - Zip Code:38506-5320
Practice Address - Country:US
Practice Address - Phone:931-537-3937
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2677152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist