MEDICARE: DR. CRAIG MATTHEW DECLARK O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	046007272	IL

General Provider Information

NPI Number	:	1033101993
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CRAIG MATTHEW DECLARK O.D.

Provider Business Mailing Address
First Line	:	6336 W GUNNISON ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60630-2954
Country	:	US
Telephone Number	:	773-763-4666
Fax Number	:	773-763-4967

Provider Business Practice Location Address
First Line	:	6336 W GUNNISON ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60630-2954
Country	:	US
Telephone Number	:	773-763-4666
Fax Number	:	773-763-4967

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/17/2005
Last Update Date	:	05/20/2008

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