Provider Demographics
NPI:1013353184
Name:MATTHEW W. GIFFORD, O.D., P.C
Entity Type:Organization
Organization Name:MATTHEW W. GIFFORD, O.D., P.C
Other - Org Name:RED EYE EYEWEAR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:W
Authorized Official - Last Name:GIFFORD
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:773-368-6471
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:773-368-6471
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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-16
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046009054152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILU70344Medicare UPIN
ILK11460Medicare PIN