Basic Information
Provider Information | |||||||||
NPI: | 1841209632 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | TODD | ||||||||
FirstName: | MATTHEW | ||||||||
MiddleName: | JUSTIN | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M. D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 70 | ||||||||
Address2: |   | ||||||||
City: | CHATTANOOGA | ||||||||
State: | TN | ||||||||
PostalCode: | 374010070 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4237783274 | ||||||||
FaxNumber: | 4237782255 | ||||||||
Practice Location | |||||||||
Address1: | 975 E 3RD ST | ||||||||
Address2: |   | ||||||||
City: | CHATTANOOGA | ||||||||
State: | TN | ||||||||
PostalCode: | 374032103 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4237783274 | ||||||||
FaxNumber: | 4237782255 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/08/2006 | ||||||||
LastUpdateDate: | 04/09/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 35973 | TN | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 3881325 | 05 | TN |   | MEDICAID | P00371032 | 01 | TN | RR MEDICARE | OTHER | TN0100 | 01 | TN | JDEERE | OTHER | 1841209632 | 01 | TN | NPI | OTHER | 3881325 | 01 | TN | WELLCARE | OTHER | 4134582 | 01 | TN | BLUE SHIELD | OTHER |