Provider Demographics
NPI:1124401773
Name:GIFFORD, MATTHEW (OD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:GIFFORD
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 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5111 N MAIN ST REET
Practice Address - Street 2:STE 200
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545
Practice Address - Country:US
Practice Address - Phone:574-277-8121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-01
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003913A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201299850Medicaid
IN544150017Medicare PIN