Provider Demographics
NPI:1669598041
Name:TERWILLEGAR, MATT (OD)
Entity type:Individual
Prefix:DR
First Name:MATT
Middle Name:
Last Name:TERWILLEGAR
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2200 BRIARCREST DR STE 106
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77802-5001
Mailing Address - Country:US
Mailing Address - Phone:979-774-5400
Mailing Address - Fax:979-731-8483
Practice Address - Street 1:2200 BRIARCREST DR STE 106
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802-5001
Practice Address - Country:US
Practice Address - Phone:979-774-5400
Practice Address - Fax:979-731-8483
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5627T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXU71904Medicare UPIN