Healthcare Provider Details

I. General information

NPI: 1730172271
Provider Name (Legal Business Name): TRACY L MATCHINSKI OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2005
Last Update Date: 01/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3241 S MICHIGAN AVE
CHICAGO IL
60616-3849
US

IV. Provider business mailing address

3241 S MICHIGAN AVE
CHICAGO IL
60616-3849
US

V. Phone/Fax

Practice location:
  • Phone: 312-225-6200
  • Fax: 312-949-7660
Mailing address:
  • Phone: 312-949-7252
  • Fax: 312-949-7638

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046008902
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: