Organization
2020 ILLINOIS PC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DAVID GIBSON OD (CHIEF MEDICAL OFFICER)
(919) 880-6066
Entity
Organization
Contact information
Practice address
1047 OAKWOOD AVE, DES PLAINES, IL 60016-6332
(617) 356-8117
Mailing address
33 ARCH ST FL 17, BOSTON, MA 02110-1424
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1376644831
NPI TYPE 1
—
Enumeration date
07/12/2019
Last updated
07/12/2019
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