Healthcare Provider Details

I. General information

NPI: 1013353184
Provider Name (Legal Business Name): MATTHEW W. GIFFORD, O.D., P.C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2013
Last Update Date: 02/11/2020
Certification Date: 02/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2158 N DAMEN AVE
CHICAGO IL
60647-9597
US

IV. Provider business mailing address

2158 N DAMEN AVE
CHICAGO IL
60647-9597
US

V. Phone/Fax

Practice location:
  • Phone: 773-368-6471
  • Fax:
Mailing address:
  • Phone: 773-368-6471
  • Fax: 773-782-1501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046009054
License Number StateIL

VIII. Authorized Official

Name: DR. MATTHEW W GIFFORD
Title or Position: PRESIDENT
Credential: DO
Phone: 773-368-6471