Provider Demographics
NPI:1093860603
Name:KORESCH, KENNETH JOE (OD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:JOE
Last Name:KORESCH
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 1:5308 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515-5118
Mailing Address - Country:US
Mailing Address - Phone:630-960-4167
Mailing Address - Fax:
Practice Address - Street 1:1987 W GALENA BLVD.
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60506-4305
Practice Address - Country:US
Practice Address - Phone:630-892-6610
Practice Address - Fax:630-892-6619
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2009-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046007057152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILU45481Medicare UPIN
L28695Medicare PIN