Provider Demographics
NPI:1841209632
Name:TODD, MATTHEW JUSTIN (M D)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:JUSTIN
Last Name:TODD
Suffix:
Gender:M
Credentials:M D
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 70
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37401-0070
Mailing Address - Country:US
Mailing Address - Phone:423-778-3274
Mailing Address - Fax:423-778-2255
Practice Address - Street 1:975 E 3RD ST
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37403-2103
Practice Address - Country:US
Practice Address - Phone:423-778-3274
Practice Address - Fax:423-778-2255
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN35973207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3881325Medicaid
TNP00371032OtherRR MEDICARE
TNTN0100OtherJDEERE
TN1841209632OtherNPI
TN3881325OtherWELLCARE
TN4134582OtherBLUE SHIELD
TN3881325Medicaid