Provider Demographics
NPI:1588749030
Name:DEGROOT, MATTHEW R (OD)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:R
Last Name:DEGROOT
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 1:2 W TALCOTT
Mailing Address - Street 2:SUITE 30
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068
Mailing Address - Country:US
Mailing Address - Phone:847-696-2434
Mailing Address - Fax:847-696-1481
Practice Address - Street 1:2 W TALCOTT
Practice Address - Street 2:SUITE 30
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068
Practice Address - Country:US
Practice Address - Phone:847-726-2020
Practice Address - Fax:847-726-2036
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U97583Medicare UPIN
ILK02074Medicare ID - Type Unspecified