Provider Demographics
NPI:1295855385
Name:CRAIG M. DECLARK, O.D.,P.C.
Entity Type:Organization
Organization Name:CRAIG M. DECLARK, O.D.,P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:MATTHEW
Authorized Official - Last Name:DECLARK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:773-763-4666
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-30
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-007272152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
T37614Medicare UPIN
0475750001Medicare NSC
613510Medicare PIN
410047996Medicare PIN