Provider Demographics
NPI:1891788212
Name:JOHN, KERRY M (OD)
Entity Type:Individual
Prefix:DR
First Name:KERRY
Middle Name:M
Last Name:JOHN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:KERRY
Other - Middle Name:M
Other - Last Name:NAVIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:715 W HILLGROVE AVE
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:IL
Mailing Address - Zip Code:60525-5964
Mailing Address - Country:US
Mailing Address - Phone:708-482-3200
Mailing Address - Fax:708-482-3288
Practice Address - Street 1:715 W HILLGROVE AVE
Practice Address - Street 2:
Practice Address - City:LA GRANGE
Practice Address - State:IL
Practice Address - Zip Code:60525-5964
Practice Address - Country:US
Practice Address - Phone:708-482-3200
Practice Address - Fax:708-482-3288
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046009289152WC0802X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046009289Medicaid
IL046009289Medicaid