Provider Demographics
NPI:1396834602
Name:GIFFORD, MATTHEW W (OD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:W
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 1:2158 N DAMEN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-9597
Mailing Address - Country:US
Mailing Address - Phone:773-782-1660
Mailing Address - Fax:773-782-1501
Practice Address - Street 1:2158 N DAMEN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-9597
Practice Address - Country:US
Practice Address - Phone:773-368-6471
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-009054152WC0802X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
U70344Medicare PIN
ILU70344Medicare UPIN
ILK11460Medicare ID - Type UnspecifiedOPTOMETRIST