Provider Demographics
NPI:1003925280
Name:JOSHUA L. KORSGARDEN, O.D., LTD.
Entity Type:Organization
Organization Name:JOSHUA L. KORSGARDEN, O.D., LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:L
Authorized Official - Last Name:KORSGARDEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:630-650-2041
Mailing Address - Street 1:139A GILLETT ST
Mailing Address - Street 2:
Mailing Address - City:SUGAR GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60554-9323
Mailing Address - Country:US
Mailing Address - Phone:630-650-2041
Mailing Address - Fax:
Practice Address - Street 1:472 N STATE ROUTE 47
Practice Address - Street 2:SUITE E
Practice Address - City:SUGAR GROVE
Practice Address - State:IL
Practice Address - Zip Code:60554
Practice Address - Country:US
Practice Address - Phone:630-466-4646
Practice Address - Fax:630-466-4848
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2010-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046009658152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL3091Medicare PIN
IL209785Medicare ID - Type Unspecified
ILV01241Medicare UPIN