MEDICARE: DR. TERRISA JO DRAKE O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152WV0400X	Vision Therapy Optometrist	5817TG	TX
2	152WX0102X	Occupational Vision Optometrist	5817TG	TX
3	207WX0009X	Glaucoma Specialist (Ophthalmology) Physician	5817TG	TX
4	152W00000X	Optometrist	5817TG	TX
5	152WC0802X	Corneal and Contact Management Optometrist	5817TG	TX
6	152WP0200X	Pediatric Optometrist	5817TG	TX
7	152WS0006X	Sports Vision Optometrist	5817TG	TX

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	488959ZUNK	OTHER	TX	MEDICARE GROUP MEMBER PROVIDER NUMBER

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1134275761
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TERRISA JO DRAKE O.D.

Provider Business Mailing Address
First Line	:	1706 SW LOOP 410 STE 102
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78227-1676
Country	:	US
Telephone Number	:	726-999-3632
Fax Number	:	726-999-3633

Provider Business Practice Location Address
First Line	:	1706 SW LOOP 410 STE 101
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78227-1676
Country	:	US
Telephone Number	:	726-999-3632
Fax Number	:	726-999-3633

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/26/2007
Last Update Date	:	02/19/2019

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