Healthcare Provider Details

I. General information

NPI: 1962668624
Provider Name (Legal Business Name): MICHAEL CARLO GIOVINGO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2008
Last Update Date: 04/23/2021
Certification Date: 04/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

243 CHARLES ST GLAUCOMA CLINIC
BOSTON MA
02114
US

IV. Provider business mailing address

150 E HURON ST STE 1000
CHICAGO IL
60611-2947
US

V. Phone/Fax

Practice location:
  • Phone: 617-523-7900
  • Fax:
Mailing address:
  • Phone: 312-337-1285
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number036130412
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207WX0009X
TaxonomyGlaucoma Specialist (Ophthalmology) Physician
License Number036130412
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: