Provider Demographics
NPI:1033101993
Name:DECLARK, CRAIG MATTHEW (OD)
Entity Type:Individual
Prefix:DR
First Name:CRAIG
Middle Name:MATTHEW
Last Name:DECLARK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6336 W GUNNISON ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60630-2954
Mailing Address - Country:US
Mailing Address - Phone:773-763-4666
Mailing Address - Fax:773-763-4967
Practice Address - Street 1:6336 W GUNNISON ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60630-2954
Practice Address - Country:US
Practice Address - Phone:773-763-4666
Practice Address - Fax:773-763-4967
Is Sole Proprietor?:No
Enumeration Date:2005-08-17
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046007272152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
K49686Medicare PIN
IL613510Medicare ID - Type Unspecified
0475750001Medicare NSC
ILT37614Medicare UPIN
410047996Medicare PIN