Provider Demographics
NPI:1134275761
Name:DRAKE, TERRISA JO (OD)
Entity type:Individual
Prefix:DR
First Name:TERRISA
Middle Name:JO
Last Name:DRAKE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:1706 SW LOOP 410 STE 102
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78227-1676
Mailing Address - Country:US
Mailing Address - Phone:726-999-3632
Mailing Address - Fax:726-999-3633
Practice Address - Street 1:1706 SW LOOP 410 STE 101
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78227-1676
Practice Address - Country:US
Practice Address - Phone:726-999-3632
Practice Address - Fax:726-999-3633
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-26
Last Update Date:2019-02-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TX5817TG152WV0400X, 152WX0102X, 207WX0009X, 152W00000X, 152WC0802X, 152WP0200X, 152WS0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
No207WX0009XAllopathic & Osteopathic PhysiciansOphthalmologyGlaucoma Specialist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX488959ZUNKOtherMEDICARE GROUP MEMBER PROVIDER NUMBER
TX1134275761Medicaid
TXU77329Medicare UPIN