Provider Demographics
NPI:1316028723
Name:DE KOSTER, LORETTA L (OD)
Entity Type:Individual
Prefix:DR
First Name:LORETTA
Middle Name:L
Last Name:DE KOSTER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 N. HARLEM AVE
Mailing Address - Street 2:
Mailing Address - City:ELMWOOD PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60707-2020
Mailing Address - Country:US
Mailing Address - Phone:708-456-4362
Mailing Address - Fax:708-456-5161
Practice Address - Street 1:2500 N. HARLEM AVE
Practice Address - Street 2:
Practice Address - City:ELMWOOD PARK
Practice Address - State:IL
Practice Address - Zip Code:60707-2020
Practice Address - Country:US
Practice Address - Phone:708-456-4362
Practice Address - Fax:708-456-5161
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2018-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046008683152W00000X
IL046.008683152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01621057OtherBLUE CROSS BLUE SHIELD
IL6375OtherDAVIS VISION
ILIL4407OtherMEDICARE PTAN
IL1316028723OtherLORETTA DE KOSTER NPI
IL113869OtherEYE CARE PLAN OF AMERICA
IL1992982169OtherNPI #1992982169 LORETTA DE KOSTER,O.D.,LTD. DBA MELROSE EYECARE CENTER
IL1992982169OtherNPI #1992982169 LORETTA DE KOSTER,O.D.,LTD. DBA MELROSE EYECARE CENTER
IL113869OtherEYE CARE PLAN OF AMERICA