Provider Demographics
NPI:1184617367
Name:MATHEWS, DENNIS E (OD)
Entity type:Individual
Prefix:
First Name:DENNIS
Middle Name:E
Last Name:MATHEWS
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 1:825 RIDGE LAKE BLVD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-9411
Mailing Address - Country:US
Mailing Address - Phone:901-685-2200
Mailing Address - Fax:901-820-2342
Practice Address - Street 1:825 RIDGE LAKE BLVD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-9411
Practice Address - Country:US
Practice Address - Phone:901-685-2200
Practice Address - Fax:901-820-2342
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS675152W00000X
TN1000152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS675OtherOD LICENSE
TN410022830OtherRR MEDICARE
AR111234722Medicaid
TN3124319OtherBCBSTN
TN1000OtherOD LICENSE
MSP01120062OtherRR MEDICARE
MS00087009Medicaid
TN3595763Medicaid
MO316826809Medicaid
MO316826809Medicaid
MM0008676OtherDEA
MSP01120062OtherRR MEDICARE
TN3124319OtherBCBSTN