Healthcare Provider Details

I. General information

NPI: 1255149258
Provider Name (Legal Business Name): TIFFANI DJORDJEVIC OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2024
Last Update Date: 10/08/2025
Certification Date: 10/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2736 N CLARK ST
CHICAGO IL
60614-1503
US

IV. Provider business mailing address

2736 N CLARK ST
CHICAGO IL
60614-1503
US

V. Phone/Fax

Practice location:
  • Phone: 773-248-8866
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046.011958
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: