1003925280 NPI number — JOSHUA L. KORSGARDEN, O.D., LTD.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003925280 NPI number — JOSHUA L. KORSGARDEN, O.D., LTD.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JOSHUA L. KORSGARDEN, O.D., LTD.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003925280
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/12/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
139A GILLETT ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SUGAR GROVE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60554-9323
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-650-2041
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
472 N STATE ROUTE 47
Provider Second Line Business Practice Location Address:
SUITE E
Provider Business Practice Location Address City Name:
SUGAR GROVE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60554
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-466-4646
Provider Business Practice Location Address Fax Number:
630-466-4848
Provider Enumeration Date:
08/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KORSGARDEN
Authorized Official First Name:
JOSHUA
Authorized Official Middle Name:
L
Authorized Official Title or Position:
PRESIDENT/OPTOMETRIST
Authorized Official Telephone Number:
630-650-2041

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  046009658 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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