=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689608507
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MATTHEW RUSSELL WARDEN O.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/10/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 589 W MAIN ST
-----------------------------------------------------
City | ALGOOD
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38506-5320
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 931-537-3937
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 519 MASON RD
-----------------------------------------------------
City | COOKEVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38501-7928
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 931-372-7535
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 2677
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------