Healthcare Provider Details

I. General information

NPI: 1396834602
Provider Name (Legal Business Name): MATTHEW W GIFFORD O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2006
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: 773-782-1660
  • Fax: 773-782-1501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number046-009054
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046-009054
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: