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General NPI Number Information
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NPI Number | 1295855385
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Entity Type | Organization
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Legal Business Name | CRAIG M. DECLARK, O.D.,P.C.
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Dates
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Enumeration Date | 03/30/2007
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Last Update Date | 05/19/2008
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Provider Practice Location Address
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Address Line | 6336 W GUNNISON ST
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City | CHICAGO
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State | IL
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Zip | 60630-2954
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Country | US
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Telephone | 773-763-4666
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Fax | 773-763-4967
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Provider Business Mailing Address
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Address Line | 6336 W GUNNISON ST
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City | CHICAGO
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State | IL
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Zip | 60630-2954
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Country | US
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Telephone | 773-763-4666
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Fax | 773-763-4967
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. CRAIG MATTHEW DECLARK
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Credential | O.D.
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Telephone | 773-763-4666
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 046-007272
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License Number State | IL
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